2023 ATI CAPSTONE ADULT MEDICAL
SURGICAL ASSESSMENT 2 WITH NGN
QUESTIONS AND VERIFIED ANSWERS
1. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's
disease. Which of the following information should the nurse include in the teaching?
Explain p...
1 2023 ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT 2 WITH NGN QUESTIONS AND VERIFIED ANSWERS 1. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching? Explain procedures in full detail to client before initiating care Limit a client’s activities to minimize emotional outbursts Speak clearly and loudly to a client who is unable to form words or sentences Provide supervision to prevent a client from becoming injured or lost A client who has Alzheimer's disease can wander and become lost. The AP should initiate interventions to keep the client safe, such as redirection, frequent monitoring, and reorientation. The AP should encourage a client who has Alzheimer's disease to participate in activities for as long as possible because socializing with others can provide the client with comfort = D 2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan? Inspect the pin site every 4 hr Monitor the client’s skin under the halo vest Ensure two personnel hold the halo device when repositioning the client Apply powder frequently to the client’s skin under the vest to decrease itching The nurse should monitor the client’s skin that is under the halo vest for excessive sweating, redness, or blistering which can lead to skin breakdown and infection. To ensure the vest is not causing pressure, the nurse should be able to insert one finger between the jacket and the skin with ease = B 3. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily Consume high -calorie foods Limit caffeinated drinks to two per day Drink fluids during meal time The nurse should instruct the client to consume high -calorie, high -protein foods to provide energy and prevent weight loss = B 4. A nurse is caring for a client who has anew diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease? Contact precautions Airborne precautions 2 Droplet precautions Protective environment 3 Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. For airborne precautions, the client should be placed in a private, negative pressure room with 6 – 12 air exchanges per hour with HEPA filtration. The nurse should wear an N95 respirator while providing care to the client. Nurse should also teach client to cough and expectorate sputum into tissues, which are disposed of in a waterproof sack = B 5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol Pancuronium Promethazine Pentoxifylline The nurse should identify that propofol is a short -acting anesthetic medication that can be used to cause moderate sedation for procedures, such as a colonoscopy = A 6. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis? Early menopause History of falls African American race Obesity A client who goes into early menopause, form natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Decreased estrogen leads to an increase in bone decay & decrease in the production of osteoclasts that produce new bone. Osteoporosis is the most common metabolic bone disorder that results in low bone density. It occurs when the rate of bone resorption exceeds the rate of bone formation, resulting in fragile bone tissue and subsequent fractures = A 7. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider? The dressing was changed 7 days ago The circumference of the client’s upper arm has increased by 10% The catheter has not been used in 8 hr The catheter has been flushed with 10 mL of sterile saline after medication use Circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion & then again during assessments. An increase in the circumference could indicate deep vein thrombosis, which could be life threatening. The nurse should conta ct the provider immediately about this finding = B
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