ATI Capstone Med Surg 1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should
... [Show More] the nurse include in the plan? a) Ask the client to tilt their head back when swallowing. b) c) Administer liquids to the client using a syringe. d) Allow the client to rest for 10 min prior to eating. 2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red and there is warmth along the course of the vein. Which of the following actions should the nurse take? a) Initiate a new IV line below the original insertion site. b) c) Raise the head of the bed d) Obtain a culture from the area of the insertion site. 3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take? a) Document shiny, taut skin as an expected finding. b) c) Listen for 1 min before documenting absent bowel sounds d) Perform auscultation immediately after the client has consumed a meal. Have the client sit upright for 1 hr. following meals. Discontinue the infusion Perform palpitation after auscultation. contact: [email protected] lOMoARcPSD|15000798 4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as a part of the which of the following types of immunity? a) Passive immunity b) Active immunity c) Cellular immunity d) 5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify that which of the following is a risk factor that places older clients at an increased risk for developing infections? a) Overproduction of lymphocytes b) Elevated albumin levels c) d) Increased body fat 6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the following instructions should the nurse include in the teaching? a) Hold your breath for 6 seconds after inhaling the medication. b) c) Do not shake the medication in the inhaler d) Hold the inhaler 3 inches away from your mouth. 7. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect? a) Pulse oximetry reading of 95 % b) Decreased depth of respirations c) d) Respiratory rate of 16/min Acquired immunity Lowered immune system function Inhale the medication deeply for 5 seconds. Flaring of the nostrils lOMoARcPSD|15000798 8. A nurse is teaching a client about the correct use of a cane. Which of the following instruction should the nurse include in the teaching? (Selected all that apply) a) b) Hold the cane on the weaker side. c) d) Move the cane and stronger leg forward simultaneously e) 9. A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching? a) Increase in subcutaneous tissue b) Decrease in pigmentation c) Increase in moisture levels d) 16. A nurse s providing teaching about measures to promote sleep with a client who has insomnia. Which of the following client statements indicates an understanding of the teaching? a) “I can exercise as late as 2 hours before bedtime.” b) c) “I should take a 1 hours nap each day” d) “I can eat a large meal as late as 1 hours before bedtime” 17. A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use? a) Numerical pain scale b) Verbal description Ensure the cane has a rubber cap. Flex the elbow slightly when using the cane. Use a quad cane for increased support. Decrease in elasticity “I should reduce my fluid intake 2 hours before bedtime “ lOMoARcPSD|15000798 c) Faces pain scale d) 18. A nurse in an emergency department is monitoring the hydration status of a client who is receiving oral rehydration. Which of the following findings should the nurse identify as requiring further interventions? a) b) BP 121/74 mm Hg c) Temperature 37.78 C (100 F) d) Urine specific gravity 1.020 19. A nurse in a provider’s office is assessing the motor skill development of a 15 month oldtoddler during a well child visit. Which of the following gross motor skills should the nurse expect? a) Takes several steps on tip toes b) c) Has an accentuated cervical curvature when standing d) Stands with the feet turned slightly inward. 20. A nurse is teaching a group of parents and guardians about safety risks for adolescents. Which of the following statements should the nurse include in the teaching? a) “Exploring the environment commonly leads to injuries for this age group.” b) “Most injuries sustained during this time of life are caused by developing motor skills.”c) d) The risk for injuries sustained during this age are often a result of a changes in cognitive function” 21. A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of thefollowing actions should the nurse take? Behavioral indicators Heart rate 120/min Walks without assistance using a wide stance “At this age, peer influence to participate in high -risk behaviors can lead to injury” lOMoARcPSD|15000798 a) b) Discuss the competency of the surgeon with the client c) Inform the client that others have had the procedure without problems. d) Ask the client why they are experiencing anxiety. 22. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching? a) “I need to have an attorney sign my advance directives”b) c) “I must have a family member appointed to make my health care decisions” d) “I will need to sign a document stating that I want to be resuscitated if I required CPR.” 23. A nurse is planning a community education program about colorectal cancer. Which of thefollowing risk factors should the nurse identify as modifiable? (Select all that apply) a) Smoking b) c) Inflammatory bowel disease d) e) Colorectal polyps 24. A nurse is reviewing the laboratory report of a client who has been experiencing a fever for the last 3 days. Which of the following laboratory results indicates the client is experiencing fluid volume deficit? a) Decreased blood urea nitrogen (BUN) b) c) Decreased urine specific gravity Ask the client to describe their feelings “I have a living will that outlines my wishes if I am unable to make decisions” Alcohol consumption High-fat diet Increased hematocrit lOMoARcPSD|15000798 d) Increased calcium level 25. A charge nurse discovered that a nurse did not notify the provider that a client’s conditionhad changed. The charge nurse should identify that the nurse is accountable for which of the following torts? a) Negligence b) Slander c) Invasion of privacy d) Libel 26. A nurse is performing a cultural assessment of a group of clients to maintain respect for theirvalue systems and beliefs. Which of the following should the nurse identify as examples of cultural variables? (Select all that apply). a) b) c) Level of education d) Touch e) Blood Type 27. A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client’s history and assessment? a) Insert an intravenous catheter to begin fluid therapy b) Develop actions to address the client’s manifestationsc) d) Determine the effectiveness of treatment. 28. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take? a) Mix the medications together and administer through the NG tube . Eye contact Personal space Identify the client’s needs lOMoARcPSD|15000798 b) Crush the sublingual medication into powder form c) d) Flush the tube with 5 ml saline between each medication. 29. A nurse is preparing to perform a sterile dressing change for a client who has surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change? a) Remove a piece of the new dressing that falls 5cm(2in) from the edge of the sterile fieldduring the dressing change. b) Begin the dressing change by applying sterile gloves and removing the existing dressingc) the solution into the dressing tray d) Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. 31. A nurse is reviewing the health history of an older adult client who has a hip fracture . The nurse should identify that which of the following findings places the client at risk for developing a pressure injury? a) Osteoporosis b) c) Macular degeneration d) Psoriasis 32. A nurse is performing a focused assessment for a client who has dysrhythmia. Which of thefollowing indicates ineffective cardiac contractions? a) Carotid bruit b) Heart murmur c) Dissolve crushed tablet medications in sterile water. Restart the procedure if the sterile solution splashes onto the sterile flied when pouring Urinary incontinence Pulse deficit [Show Less]