ATI CAPSTONE Medical Surgical Assessment 1- LATEST
correct and verified Answers- WITH EXPLANATION
Med Surg Assessment 1
1. A nurse is planning care for
... [Show More] 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
i. Use electronic tablet, computer, programmable speech generating device,
alphabet board, pencil and paper, etc.
2. 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. Urine specific gravity 1.020
i. Within the expected range of 1.005 – 1.030
3. A nurse is monitoring the laboratory findings for a client who is postoperative following a total
hip arthroplasty 6 hours ago. Which of the following values indicates that the client has an
increased risk for bleeding?
a. Platelets 80,000
i. Platelet range is 150,000 – 400,000
4. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle
accident. Which of the following interventions is the nurse’s priority while caring for this client?
a. Assist the client with quad coughing
i. The greatest risk to a client who has a cervical spinal cord injury is an obstructed
airway; the priority is to ensure that the client can clear their airway. Apply
abdominal pressure as the client coughs (quad coughing).
5. 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?
a. Dyspnea
i. Dyspnea is an indication of possible transfusion-associated circulatory overload,
leading to hypertension, bounding pulses, and confusion. Dyspnea can also
indicate transfusion related acute lung injury to an anaphylactic response, which
also causes wheezing, chest tightness, cyanosis and low BP.
6. A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the
chest. Which of the following indicates an adverse effect of the therapy?
a. Altered taste sensations
i. Altered taste is a result of the release of metabolites by dead cells
7. A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of
the following actions should the nurse plan to take? SATA:
a. Obtain pre-transfusion temperature
i. Complete assessment prior to transfuion
b. Verify the client’s blood type with a second nurse
i. Verify ID, blood compatibility, and expiration of product with second nurse
c. Use a 20-gauge-IV needle for venous access
i. The nurse should use a large-bore needle to transfuse the PRBCs to reduce the
risk of cell hemolysis and obstruction of flow
8. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the
following BUN levels should the nurse expect?
ATI CAPSTONE Medical Surgical Assessment 1- LATEST
correct and verified Answers- WITH EXPLANATION
a. 26 mg/dL
ATI CAPSTONE Medical Surgical Assessment 1- LATEST
correct and verified Answers- WITH EXPLANATION
i. Normal range is 10-20, and elevated levelsindicate renal disease, dehydration,
shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or
other conditions in which blood is reabsorbed from injured tissues
9. A nurse is reviewing ECG strips forseveral clients. Which of the following images should the
nurse identify as atrial fibrillation?
a. Multiple irregular and variable waves at the baseline and irregular R to R waves
10. 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
i. The obturator can be inserted in the stoma in the event of dislodgment or
decannulation to maintain an airway until a trach tube can be placed. For the
first 72 hoursfollowing the insertion of the trach, dislodgment or decannulation
is considered an emergency.
11. 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.”
12. 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. “Shake the inhaler vigorously prior to use.”
i. Thoroughly shake the inhaler to disperse the medication because the
medication in the inhaler can separate easily
13. A nurse in an endoscopy clinic is providing teaching to a client who is to under go a colonoscopy
for colon cancer screening. Which of the following information should the nurse provide?
a. “You will need someone to drive you home after your procedure?”
i. Do not drive for 12-18 hours following the procedure, because during a
colonoscopy, the patient receives moderate sedation
14. 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. No response to verbal stimuli
i. Using urgent vs non-urgent approach, this is the priority; during moderate
sedation, the patient should be able to provide a response to questions and
commands. No response to verbal stimuli can indicate a loss of consciousness or
over sedation.
15. 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. Potassium 3.2 mEq/L
i. Loop diureticsremove excessive extracellular fluid through the kidneys, causing
an increased excretion of potassium; monitor for dysrhythmias
16. A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the
nurse take? SATA: [Show Less]