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RN ATI CAPSTONE MED SURG EXAM NEWEST
2024 ACTUAL EXAM 150 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
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. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold - ....ANSWER...C Altered taste sensations Altered taste is a result of the release of metabolites by dead cells 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 (select all that apply) A. Obtain pre-transfusion temperature B. Prime the IV tubing with lactated Ringer's C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access - ....ANSWER...A, D, E A, complete assessment prior to transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18. mg/dL D. 26 mg/dL - ....ANSWER...D 26 mg/dL Normal range is 10 - 20, and elevated levels indicates 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 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)
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" - ....ANSWER...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" - ....ANSWER...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 - ....ANSWER...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 - ....ANSWER...C. Potassium 3. mEq/L Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias
C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep - ....ANSWER...A) Lock doors leading to stairways This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet B. Perform a vascular assessment for the client every 6 hr C. Maintain the head of the client's bed at 15 degrees at all times D. Place the client on contact precautions - ....ANSWER...A) Keep the client's room dark and quiet Meningitis often causes photophobia and phonophobia. Reduce stimuli A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take A. Ask the client to exhale slowly B. Turn the client's head to the right C. Place the client in a semi fowlers position D. use aseptic technique - ....ANSWER...D use aseptic technique
aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client A. Recombinant herpes zoster B. Human papillomavirus C. Live attenuated influenza D. Varicella - ....ANSWER...A) Recombinant herpes zoster herpes zoster= shingles Older adults can get either the live or recombinant herpes zoster immunization A nurse is caring fro a client who has continuous bladder irrigation following a transurthral resection of the prostate (TURP). Which of he following actions should the nurse take A. Place the indwelling urinary catheter tubing so it lies freely between the client's legs B. Irrigate the indwelling urinary catheter using sterile water C. Subtract the amount of irrigation solution from the indwelling urinary catheter output D. Flush the indwelling urinary catheter with 30mL of irrigation solution to clear an obstruction -
A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of the teaching A. "I will wear my graduated compression stockings while sleeping" B. "I will elevate my legs for 10 minutes 3 times per day" C. "I will limit the time I spend sitting down during the day" D. "I will cross my legs at my knees when sitting" - ....ANSWER...C) "I will limit the time I spend sitting down during the day" Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommendations should the nurse include in the teaching? A. "Try to avoid sun exposure by waiting until after sunset to go outdoors" B. "Gently was the irradiated area to remove the markings before going outside" C. "Protect exposed skin with an over the counter sunscreen" D. "Wear form sitting clothing when going outside" - ....ANSWER...A) "Try to avoid sun exposure by waiting until after sunset to go outdoors"
Protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. Stay in the shade, go outside in the early morning or evening to avoid the more intense sun rays to allow the pt to stay outside for a longer period A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL - ....ANSWER...A ) Increased troponin Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2 - 3 hr following an MI A nurse is preparing to obtain blood cultures from a client's central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter A. Flush the lumen with heparin solution before each use B. Aspirate for blood return prior to each use C. Perform a 5 second scrub to the catheter hub before accessing the catheter
A. Suction the client's airway every 4 hours B. Limit the client's fluid intake to control secretions C. Provide the client with a high protein diet D. Administer the client's bronchodilator following each meal - ....ANSWER...C) Provide the client with a high protein diet COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals A nurse is administering parenteral nutrition to a client who has a history of heart failure. Which of the following manifestations indicates to the nurse that the client is experiencing fluid overload A. hypotension B. flattened neck veins C. nocturia D. weight loss - ....ANSWER...C when the client is recumbent, the extracellular fluid enters the vascular system and increases the blood volume filtering through the kidneys, which increases urine production -- A, hypertension indicates fluid overload in a pt with heart failure B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure A nurse is teaching the caregiver of a client who has mild alzheimer's disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's disease A. Short term memory loss B. misplacement of household items C. Episodes of wandering D. loss of mobility - ....ANSWER...C) Episodes of wandering Wandering occurs in the moderate stage of AD A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to heart failure. Which of the following statements by the client indicates an understanding of the teaching A. "I will limit my dietary sodium intake to 4 grams per day" B. "I should weigh myself once a week" C. "I plan to wait 2 hours after eating to take my walk" D. "I will take my diuretic before going to bed at night" - ....ANSWER...C To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise --
C. Flush the blood tubing with 0.9% sodium chloride D. Instruct the client to report itching or shortness of breath - ....ANSWER...B) Check the client's medical record to verify the provider's prescription The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure A. "Avoid straining to have a bowel movement" B. "Avoid lying on your right side" C. "Avoid lifting objects that weigh more than 5 pounds" D. "Avoid sleeping with your head elevated" - ....ANSWER...A Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure A nurse is providing teaching about health promotion activities to an older adult client. Which of the following recommendations should the nurse include in the teaching A. "Maintain your dietary fat intake at 45% of your daily caloric intake"
B. "Obtain 15 minutes of sunlight exposure 3 times per week" C. "Exercise for 30 minutes twice per week" D. "Decrease your fiber intake to less than 20 grams per day" - ....ANSWER...B) "Obtain 15 minutes of sunlight exposure 3 times per week" Instruct the client to obtain at least 10 - 15 min of exposure to sunlight 2 - 3 times per week to ensure adequate vitamin D production 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" - ....ANSWER...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
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 - ....ANSWER...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 A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia - ....ANSWER...C Dyspnea 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
A nurse is caring for a client who has an above the knee amputation related to trauma and is experiencing phantom limb pain. Which of the following medications should the nurse administer to treat the client's pain? A. Meloxicam B. Cyclobenzaprine C. Gabapentin D. Lidocaine - ....ANSWER...C) Gabapentin phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflammatory response syndrome (SIRS)? A. WBC count 14,000/mm B. Platelets 110,000/ mm C. Lactic acid 19 mg/dL D. C reactive protein 2.8 mg/L - ....ANSWER...A. ) WBC count 14,000/mm WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms the body's defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow's
