ATI Capstone Med Surg, Capstone Med Surg Assessment 1
a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. what
would the nurse expect to see
- pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3), what should the
nurse anticipate as the cause of these s/s
- HF
a nurse is administering potassium chloride elixer 40mEq divided into 2 equal doses every 12 hours,
available is 6.7 mEq/5mL. how many mL should the nurse administer per dose?
- 30mL
a nurse is caring for a pt in the ED who was just admitted with chest pain, possible acute coronary
syndrome. what should the nurse do first?
- administer sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
a nurse is caring for pt who is experiencing ventricular tachycardia with a pulse, the RRT is at the
bedside. what electrical intervention should be used to correct this dysrhythmia?
- synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
a nurse is caring for an adult pt who is experiencing delayed wound healing, which of the following
interventions should the nurse take?
- monitor serum albumin levels and notify provider if below 3.5g/dL
(lack of protein increases the risk for a delay in wound healing and infection)
a nurse is teaching a client who has pre-dialysis ESKD about diet, what should be included?
- reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
a nurse is caring for a client who has T1DM, the nurse misread the client's morning BG level as
210mg/dL, instead of 120mg/dL and administered the insulin dose appropriate for a reading over
200mg/dL before the client's breakfast, what action is the nurse's priority?
- monitor the client for hypoglycemia
a nurse is planning care for a pt who has a new diagnosis of DI, which of the following interventions
should the nurse include in the plan of care?
- check urine specific gravity
, a nurse is caring for a pt admitted with wheezing and coughing due to an allergic reaction to a newly
prescribed medication, what medication should be administered first?
- albuterol 3mL via nebulizer
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 that she smokes, her heart rate is 110/min, RR 40/min, and
BP 140/80, her ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3 20, SaO2 86%, what is the priority of
nursing interventions
- administer oxygen via face mask
a nurse is caring for a pt following repair of a fracture, what finding should alert the nurse that the pt is
experiencing compartment syndrome?
- unrelieved pain, pallor, pulselessness, numbness, pins and needles sensation, swelling, tightness of the
effected extremity
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 abdominal cramps, what action should the nurse take to relieve the
client's comfort
- lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what action should the nurse
take?
- place the clients bedside table on the right side of the bed
a nurse is caring for a pt who is at risk for shock, what finding is the earliest indicator that this
complication is developing?
- narrowing pulse pressure
a nurse is assessing a client who has hypokalemia as a result of n/v, and diarrhea, what finding should
the nurse expect
- weak, irregular pulse
a nurse is providing teaching for a client who has experienced an acute episode of gastritis, what
instruction should the nurse include in the teaching?
- avoid drinking alcohol
a nurse at an outpt surgery center is providing discharge teaching to a pt an his spouse following surgical
removal of a cataract, what should the nurse include?
- the client should wear dark glasses while outdoors
a nurse is assessing a pt who has a puncture wound on his foot, what is a manifestation of acute
osteomylitis?
- localized erythema
a nurse is monitoring a pt who had a cerebral aneurysm rupture, what finding should the nurse identify
as a manifestation of increased intracranial pressure
- irritability
