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CAPSTONE MED SURG RN ATI VERSION C NEWEST 2024 ACT(1)
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CAPSTONE MED SURG RN ATI VERSION C NEWEST 2024 ACT(1)
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CAPSTONE MED SURG RN ATI VERSION CWhich finding requires immediate intervention when planning care for an adolescent
with cystic fibrosis (CF)?
a) large, foul-smelling, and bulky stools
b) chest pain with dyspnea
c) poor weight gain
d) delayed puberty - ANSWER: b) chest pain with dyspnea
Chest pain and dyspnea are signs of a pneumothorax and should be treated
immediately. Delayed puberty is common in adolescents with CF and is caused by
poor nutrition. Poor weight gain is common in children with CF because so little is
absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance
with taking enzymes and should be addressed, but respiratory complications are the
greatest concern.
Which precautions should the health care team observe when caring for clients with
hepatitis A?
a) wearing gloves when giving direct care
b) wearing a mask when providing care
c) gowning when entering a client's room
d) assigning the client to a private room - ANSWER: a) wearing gloves when giving
direct care
Contact precautions are recommended for clients with hepatitis A. This includes
wearing gloves for direct care. A gown is not required unless substantial contact with
the client is anticipated. It is not necessary to wear a mask. The client does not need
a private room unless incontinent of stool.
A nurse observes an LPN measuring a client's urine output from an indwelling
catheter drainage bag. Which observation by the nurse ensures that the client's
urine has been measured accurately?
a) The LPN pours the urine into a graduated measuring container.
b) The LPN pours the urine into a paper cup that holds approximately 250 mL.
c) The LPN holds the Foley drainage bag up to eye level.
d) The LPN uses the measuring markings on the Foley drainage bag. - ANSWER: a)
The LPN pours the urine into a graduated measuring container.
The only means to measure urine output accurately is to use a container that has
specific markings for measuring liquid. The other options would not provide an
accurate measure of urine output.
An elderly couple who have just relocated to a long-term care facility have been
unable to obtain a shared room. A staff member at the facility states that this should
,not be a concern and implies that sexual activity between the couple likely ceased
many years ago. How should the nurse best respond to this individual's assertion?
a) "Research has shown the nature of sexual activity changes with age but that it
actually becomes more frequent."
b) "It's true that they've probably stopped having sexual activity, but it's important
for them to have companionship."
c) "That's true, but it's important for us to give them the teaching they need in order
to resume this part of their relationship."
d) "Actually it's not true that older people always stop having sexual activity when
they get older." - ANSWER: d) "Actually it's not true that older people always stop
having sexual activity when they get older."
Sexual activity need not be hindered by age. There is no evidence, however, that it
becomes increasingly frequent in late adulthood.
The client tells the nurse that he is allergic to shellfish. The nurse should ask the
client if he is also allergic to: - ANSWER: You selected: Iodine skin preparations.
Correct
Explanation:
Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor
and Betadine) or any other products containing iodine, such as dyes. Clients who are
allergic to shellfish do not necessarily have an allergy to any other substances or
seafood. (less)
Which action must a nurse perform when cleaning the area around a Jackson-Pratt
wound drain?
a) Clean from the center outward in a circular motion.
b) Wear sterile gloves and a mask.
c) Remove the drain before cleaning the skin.
d) Clean briskly around the site with alcohol. - ANSWER: a) Clean from the center
outward in a circular motion.
The nurse should move from the center outward in ever-larger circles when cleaning
around a wound drain because the skin near the drain site is more contaminated
than the site itself. The nurse should never remove the drain before cleaning the
skin. Alcohol should never be used to clean around a drain; it may irritate the skin
and, because it evaporates, has no lasting effect on bacteria. The nurse should wear
sterile gloves to prevent contamination, but need not wear a mask.
After receiving information on various forms of birth control, a young couple decides
to use a barrier method because they would like to try and conceive in 1 to 2 years.
Which barrier method uses a rubber barrier to hold spermicide against the cervix?
a) A cervical cap.
b) A vaginal sponge.
, c) A diaphragm.
d) A condom. - ANSWER: c) A diaphragm.
A diaphragm is a dome-shaped device made from latex rubber that mechanically
prevents semen from coming in contact with the cervix. It also holds a spermicidal
jelly in place against the cervix. A condom rolls over an erect penis and collects the
semen after ejaculation. A cervical cap is placed over the cervix and may be left in
place for up to 3 days. A vaginal sponge contains spermicide and is a reservoir to
hold the semen.
A client complains of abdominal discomfort and nausea while receiving tube
feedings. Which intervention is most appropriate for this problem?
a) Place the client in semi-Fowler's position while feeding.
b) Give the feedings at room temperature.
c) Change the feeding container daily.
d) Stop the feedings and check for residual volume. - ANSWER: d) Stop the feedings
and check for residual volume.
Complaints of abdominal discomfort and nausea are common in clients receiving
tube feedings. Stopping the feeding and checking for residual volume helps assess
the reason for the client's nausea and discomfort. If residual volume is greater than
100 ml, hold the feeding and notify the physician. Feedings are normally given at
room temperature to minimize abdominal cramping; however, this action doesn't
help assess why nausea and discomfort are occurring. Elevating the head of the
client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding
containers are changed daily to prevent bacterial growth.
The nurse is caring for a client with a Jackson-Pratt drain. Which of the following
would be the most appropriate action by the nurse?
a) Attach the tube to straight drainage to monitor the output.
b) Irrigate the drain with normal saline to ensure patency.
c) Ensure that the drainage receptacles are kept compressed to maintain suction.
d) Leave the drain open to the air to ensure maximum drainage. - ANSWER: c)
Ensure that the drainage receptacles are kept compressed to maintain suction.
Portable wound drainage systems are self-contained and can be emptied and
compressed to reestablish negative pressure, which promotes drainage. The other
choices are incorrect because a Jackson-Pratt drain needs negative pressure in the
bulb to promote drainage.
A client has a wound with a drain. When performing wound cleansing around the
drain, the nurse should cleanse in which direction?
a) From the superior portion of the wound to the inferior
b) Laterally, from one side of the wound to the opposite side
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