ATI Capstone Med Surg Assessment 1
a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. what would the
... [Show More] nurse expect to see
- 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
- 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? - 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?
- 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? - 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?
- 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? - 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?
- 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?
- 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? - 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
- 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?
- 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
- lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what action should the nurse take?
- 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?
- 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 - 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?
- 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?
- 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? - 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 - 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
- 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 - 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
- output of burgundy colored urine
a nurse is caring for a pt who has HIV, what following lab values is the nurse's priority - CD4 T cell count 180 cells/mm3
(severely immunocompromised and at high risk of infection)
a nurse is teaching a pt who has GERD about managing his illness, what recommendations should the nurse include in the teaching
- avoid eating within 3 hours of bedtime
a nurse is a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension, the nurse notes that the potassium level is 3.3, the nurse should monitor for the complication of - cardiac dysrhythmias
a nurse is caring for a pt with who has hepatitis A, the pt asks the nurse how he might have contracted virus, which of the following a question the nurse should ask the client? - have you been to a third world country in the past
a nurse is preparing a pt for a radiation treatment who is postop following a mastectomy, the nurse should inform the pt to expect what adverse effect from the treatment? - fatigue
a nurse is in a burn tx center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy, the client's spouse asks the nurse what the procedure entails, which of the following statements made by the nurse is appropriate - large incisions will be made in the eschar to improve circulation
a nurse is assessing a pt who has a herniated lumbar disc, what finding would the nurse expect - the pt reports tingling and burning sensation in one foot
a nurse is assessing a pt who has a history of migraine headaches with aura and reports feeling a "migraine coming on", the nurse should expect the pt to report what manifestation - visual disturbance
a nurse is teaching a pt who has a new diagnosis of MS about visual changes she might experience as the disease progresses, what would she include?
- double vision
a nurse is teaching a pt who has asthma about using a peak flow meter, when a yellow zone meter reading appears, the nurse should instruct the pt to take which of the following actions - take prescribed relief meds
a nurse is assessing a pt who has Addison's disease, what manifestation would indicate they are experiencing the crisis
- hypotension
(aldosterone deficit)
a nurse is caring for pt who has acute gastritis and is NPO, the pt has a new prescription to resume oral intake, what item should the nurse offer the pt
- gelatin
a nurse is providing education to a pt who is scheduled for a barium swallow, what statement indicates understanding of the teaching?
- i will remove my metal jewelry before coming in
a nurse is caring for pt who is undergoing a liver biopsy, what instruction should the nurse provide to the pt following the procedure
- lie on your right side
a nurse is teaching a pt who has a hiatal hernia about dietary selections to maintain lower esophageal sphincter (LES) pressure, what choice by the pt indicates understanding - cheddar cheese
(avoid fried, fatty, peppermint, caffeine, tomatoes, citrus fruits, and alcohol)
a nurse is reviewing the lab results of a pt who has unstable angina and has been receiving heparin via continuous IV infusion for the past 5 days, what lab values should the nurse identify as an indication that the pt has developed HIT
- platelets 90,000
a nurse is teaching a pt who has a new diagnosis of polycystic kidney disease, what statement should the nurse include in the teaching
- apply dry heat to your abdomen when needed
a nurse is obtaining the health history of a young adult male client, what information should indicate to the nurse that the pt is at high risk for developing testicular cancer - undescended right testis
a nurse is instructing a pt's caregiver on how to position the client before administering tube feedings in the home, which demonstrates understanding?
- i will sit him up in bed
a triage nurse finds a school-age child lying in the road following a school bus crash with multiple causalities, the child has a respiratory rate of 10/min, strong distal pulses, and groans to painful stimuli, what action should the nurse take
- place an emergent category on the child's upper body and yell for help
a nurse is caring for a client who has renal failure, what ABG result would the nurse expect - ph 7.25
HCO3 20
PaCO2 35
a nurse is caring for pt who has a cerebellar tumor, what action is the nurse's priority - provide assistance with ambulation
a nurse is assessing a pt who has a spinal cord injury, what finding indicates the client might be experiencing neurogenic shock
- heart rate 52/min
a nurse is caring for a pt who has renal caliculi, what prescription by the provider is the priority action for the nurse to take
- strictly monitor intake and output
a nurse is caring for a pt who is immediately postoperative following a pheochromocytoma removal, what action is priority
- monitoring BP
a nurse is assessing a female pt who reports severe joint pain, the nurse should identify which of the following factors places the pt at risk for gout
- diuretic use
a nurse is caring for a pt who has a cervical spinal cord injury, what interventions should the nurse include in the plan of care to prevent autonomic dysreflexia
- monitor bowel movement regularity
a nurse is caring for an adult client who asks about vaccinations against communicable diseases, the nurse should inform the client that which of the following vaccines are available - Hep A, Hep B, Pneumococcal
a nurse is providing discharge instructions to a pt following a cataract surgery, the nurse should advise the pt that he can perform what activities
- cooking light house work
(avoid bending at the waist, or anything that can increase IOP) [Show Less]