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ATI Capstone Med Surg test questions and verified
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answers – A+ graded
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a nurse is reviewing the ABG results of a client who the provider suspects
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has metabolic acidosis. what would the nurse expect to see Correct ans
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- pH below 7.35
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a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart
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sound (S3), what should the nurse anticipate as the cause of these s/s
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Correct ans - HF
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a nurse is administering potassium chloride elixer 40mEq divided into 2
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equal doses every 12 hours, available is 6.7 mEq/5mL. how many mL should
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the nurse administer per dose? Correct ans - 30mL
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a nurse is caring for a pt in the ED who was just admitted with chest pain,
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possible acute coronary syndrome. what should the nurse do first?
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Correct ans - administer sublingual nitroglycerin
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(treat chest pain to reduce cardiac tissue damage)
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a nurse is caring for pt who is experiencing ventricular tachycardia with a
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pulse, the RRT is at the bedside. what electrical intervention should be used
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to correct this dysrhythmia? Correct ans - synchronized cardioversion
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(tx for afib, SVT, and v tach with a pulse)
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a nurse is caring for an adult pt who is experiencing delayed wound healing,
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which of the following interventions should the nurse take? Correct ans
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- monitor serum albumin levels and notify provider if below 3.5g/dL
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(lack of protein increases the risk for a delay in wound healing and infection)
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a nurse is teaching a client who has pre-dialysis ESKD about diet, what
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should be included? Correct ans - reduce intake of foods high in
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potassium
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(potassium clearance is impaired in ESKD)
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a nurse is caring for a client who has T1DM, the nurse misread the client's
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morning BG level as 210mg/dL, instead of 120mg/dL and administered the
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insulin dose appropriate for a reading over 200mg/dL before the client's
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breakfast, what action is the nurse's priority? Correct ans - monitor
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the client for hypoglycemia
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a nurse is planning care for a pt who has a new diagnosis of DI, which of the
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following interventions should the nurse include in the plan of care?
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Correct ans - check urine specific gravity
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a nurse is caring for a pt admitted with wheezing and coughing due to an
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allergic reaction to a newly prescribed medication, what medication should
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be administered first? Correct ans - albuterol 3mL via nebulizer
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a nurse is caring for a female client in the ED who reports SOB and pain in
the lung area, she states that she started taking BC pills 3 weeks ago and
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that she smokes, her heart rate is 110/min, RR 40/min, and BP 140/80, her
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ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3 20, SaO2 86%, what is the
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priority of nursing interventions Correct ans - administer oxygen via
face mask
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a nurse is caring for a pt following repair of a fracture, what finding should
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alert the nurse that the pt is experiencing compartment syndrome?
Correct ans - unrelieved pain, pallor, pulselessness, numbness, pins and
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needles sensation, swelling, tightness of the effected extremity
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a nurse is administering a tap water enema to a pt who is constipated,
during the administration of the enema, the client states he is having
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abdominal cramps, what action should the nurse take to relieve the client's
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comfort Correct ans - lower the height of the solution container
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a pt is diagnosed with left homonymous hemianopsia following a stroke,
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what action should the nurse take? Correct ans - place the clients
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bedside table on the right side of the bed
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a nurse is caring for a pt who is at risk for shock, what finding is the earliest
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indicator that this complication is developing? Correct ans - narrowing
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pulse pressure
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a nurse is assessing a client who has hypokalemia as a result of n/v, and
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diarrhea, what finding should the nurse expect Correct ans - weak,
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irregular pulse
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a nurse is providing teaching for a client who has experienced an acute
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episode of gastritis, what instruction should the nurse include in the
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teaching? Correct ans - avoid drinking alcohol
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a nurse at an outpt surgery center is providing discharge teaching to a pt an
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his spouse following surgical removal of a cataract, what should the nurse
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include? Correct ans - the client should wear dark glasses while
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outdoors
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a nurse is assessing a pt who has a puncture wound on his foot, what is a
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manifestation of acute osteomylitis? Correct ans - localized erythema
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a nurse is monitoring a pt who had a cerebral aneurysm rupture, what
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finding should the nurse identify as a manifestation of increased intracranial
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pressure Correct ans - irritability
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when caring for a pt with a chest tube the nurse notes continuous bubbling
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in the chest tube water seal chamber, what does this indicate Correct
ans - an air leak
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a nurse is an ED is caring for a client who had a seizure and became
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unresponsive after stating she had a sudden, severe headache, and
vomiting, the pts vital signs are as follows: BP 198/110, pulse of 82/min, RR
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of 24m/min, temp of 100.8F, what neuro disorders should the nurse suspect
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Correct ans - hemorrhagic stroke
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a nurse is caring for a pt who is 2hr postoperative following a TURP, what
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assessment should be an indication of a postoperative complication
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Correct ans - output of burgundy colored urine
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a nurse is caring for a pt who has HIV, what following lab values is the
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nurse's priority Correct ans - CD4 T cell count 180 cells/mm3
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(severely immunocompromised and at high risk of infection)
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a nurse is teaching a pt who has GERD about managing his illness, what
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recommendations should the nurse include in the teaching
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Correct ans
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- avoid eating within 3 hours of bedtime
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a nurse is a provider's office is reviewing the laboratory results of a client
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who takes furosemide for hypertension, the nurse notes that the potassium
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level is 3.3, the nurse should monitor for the complication of Correct ans
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- cardiac dysrhythmias
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a nurse is caring for a pt with who has hepatitis A, the pt asks the nurse how
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he might have contracted virus, which of the following a question the nurse
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should ask the client? Correct ans - have you been to a third world
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country in the past
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a nurse is preparing a pt for a radiation treatment who is postop following a
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mastectomy, the nurse should inform the pt to expect what adverse effect
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from the treatment? Correct ans - fatigue
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a nurse is in a burn tx center is caring for a client who is admitted with
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severe burns to both lower extremities and is scheduled for an escharotomy,
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