ATI Capstone Med Surg
a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. what would the nurse expect to see ANS: pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3), what should the nurse anticip...
ATI Capstone Med Surg
a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. what
would the nurse expect to see ANS: 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 ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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 ANS: 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? ANS: 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 ANS: lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what action should the nurse
take? ANS: 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? ANS: 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 ANS: 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? ANS: 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? ANS: 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? ANS: 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 ANS: irritability
when caring for a pt with a chest tube the nurse notes continuous bubbling in the chest tube water seal
chamber, what does this indicate ANS: an air leak
a nurse is an ED is caring for a client who had a seizure and became 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 of 24m/min, temp of 100.8F, what neuro disorders should the nurse suspect ANS: hemorrhagic
stroke
a nurse is caring for a pt who is 2hr postoperative following a TURP, what assessment should be an
indication of a postoperative complication ANS: output of burgundy colored urine
a nurse is caring for a pt who has HIV, what following lab values is the nurse's priority ANS: CD4 T cell
count 180 cells/mm3
(severely immunocompromised and at high risk of infection)
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