ATI CAPSTONE MEDICAL SURGICAL ASSESSMENT 1 & 2 ALL
100 QUESTIONS AND CORRECT WELL ELABORATED
ANSWERS WITH RATIONALES
A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere
other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - A.) multiple irregular and variable
waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the operating
room. Which of the following items is the priority for the nurse to have available in the
client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula - A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or decannulation
to maintain an airway until a new trach tube can be placed. For the first 72 hr following
the insertion of a trach, dislodgement or decannulation is considered an emergency
A nurse is caring for a client who had a below the knee amputation due to a traumatic
injury 2 days ago. Which of the following statements should the nurse use to assess
how the client is coping with this change in their body image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to make when doing your job"
C. "Let's discuss how you can adjust once you have a prosthesis"
D. "What are some possible issues that you foresee when completing self-management
tasks" - A .) "Tell me how the changes to your leg make you feel"
,A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a
colonoscopy for colon cancer screening. Which of the following information should the
nurse provide
A. "You should have nothing to eat or drink for 3 hours prior to the procedure"
B. "You should drink the bowel preparation slowly to prevent nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure" - D.) "You will need
someone to drive you home after your procedure"
Do not drive for 12-18 hours following the procedure, because during a colonoscopy,
the pt receives moderate sedation
A nurse is monitoring a client who is receiving moderate sedation with midazolam.
Which of the following findings requires immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea - B) No response to verbal stimuli
using urgent vs non-urgent approach, this is the priority. During moderate sedation, the
pt should be able to provide a response to questions and commands. No response to
verbal stimuli can indicate a loss or consciousness or oversedation
A nurse is reviewing the laboratory findings for a client who has heart failure and is
taking furosemide. The nurse should identify which of the following findings as an
adverse effect of the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia - C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys, causing an
increased excretion of potassium. Monitor for dysrhythmias
A nurse is teaching a client how to administer a medication using an inhaler with a
spacer. Which of the following instructions should the nurse include
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use" - D .) "Shake the inhaler vigorously prior to
use"
Thoroughly shake the inhaler to disperse the medication because the medication in the
inhaler can separate easily
A nurse is planning care for a client who is receiving mechanical ventilation. Which of
the following actions should the nurse include in the plan
, A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - A.) Provide the client with a means of
communication
Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness of the
treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
A nurse is monitoring the laboratory findings for a client who is postoperative following a
total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has
an increased risk for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - C Platelets 80,000
platelet range is 150,000-400,000
A nurse is admitting a client who has a cervical spinal cord injury following a motor
vehicle crash. Which of the following interventions is the nurse's priority while caring for
this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - D Assist the client with quad coughing
The greatest risk to a client who has a cervical spinal cord injury is an obstructed
airway; the priority is to ensure the client can clear their airway. Apply abdominal
pressure as the client coughs (quad coughing)
A nurse is caring for a client who is receiving a blood transfusion. Which of the following
findings indicates that the client is experiencing transfusion-associated circulatory
overload
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