RN ATI Capstone Adult Medical-Surg2

Question 1

RN ATI Capstone Adult Medical-Surg2. A nurse is caring for a client on a medical-surgical unit. (Nurses’ Notes: 1800: Client reports sudden onset pain in chest and upper back and shortness of breath. Appears anxious and uncomfortable, prominent neck veins noted. Heart sounds are muffled on auscultation. Vital Signs 1800: BP 92/64, HR 111, RR 26, SpO2 89%). The nurse should identify the client has likely developed [Select…] as evidenced by the client’s [Select…].

• cardiac tamponade / echocardiogram result
• pulmonary thromboembolism / pedal pulse strength
• myocardial infarction / abdominal assessment findings

Question 2

A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• Inspect the pin site every 48 hr.
• Monitor the client’s skin under the halo vest.
• Ensure two personnel hold the halo device when repositioning the client.
• Apply powder frequently to the client’s skin under the vest to decrease itching.

uestion 21

A nurse is caring for a client who has a sealed radioactive protein implant. Which of the following actions should the nurse take?

• Limit each visitor to 1 hour per day.
• Wear a lead apron during care.
• Place the client in a room with a roommate who has a similar condition.
• Dispose of the client’s bed linens in a regular trash can.

Question 22

A nurse is caring for a client who had a spinal cord injury 4 weeks ago. Which of the following findngs should the nurse identify as an indication the client is using an effective coping strategy?

• “I don’t think I will ever be able to drive a car again.”
• “I don’t want to talk about my injury with anyone.”
• “I would like to play wheelchair basketball when I go home.”
• “I will just wait and see if my legs start moving again.” RN ATI Capstone Adult Medical-Surg2

Question 23

A nurse is providing teaching for a client who has chronic cholecystitis. Which of the following dietary recommendations should the nurse include?

• Low-fat diet
• High-fiber diet
• Low-protein diet RN ATI Capstone Adult Medical-Surg2
• High-calorie diet

Question 24

A nurse is caring for a client who is postoperative following a transsphenoidal hypophysectomy. For which of the following findings should the nurse monitor the client?

• High urine specific gravity
• Low urine specific gravity
• Hypervolemia
• Hypertension

Question 25

A nurse is providing teaching for a client who has a new diagnosis of genital herpes. Which of the following statements should the nurse include in the teaching?

• “You should wear tight-fitting synthetic underwear.”
• “Stress can activate an outbreak.”
• “You will need to take antibiotics to cure the infection.”
• “The virus cannot be transmitted when lesions are not present.”

Question 26

A nurse is assessing a client who has multiple sclerosis and is taking dantrolene. Which of the following findings should the nurse identify as an indication that the medication is effective?

• “I have more energy throughout the day.”
• “My vision has improved since I started the medication.”
• “I don’t have muscle spasms as frequently.”
• “I have less numbness in my hands.”

Question 27

A nurse is providing teaching for a client who works at a computer station about preventing carpal tunnel syndrome. Which of the following instructions should the nurse include? (Select all that apply.)

• Use a wrist rest when working at a computer station.
• Adjust the keyboard height so it is at shoulder level.
• Stretch your fingers and wrists periodically while working.
• Take breaks from the repetitive activity.
• Maintain a forward-leaning posture while sitting in the chair.

Question 28

A nurse is reviewing the laboratory results of a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• Sticky mucous membranes
• Decreased deep-tendon reflexes
• Increased blood pressure
• Hypoactive bowel sounds

Question 35

A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?

• Stomatitis
• Fatigue
• Wasting syndrome
• Lipodystrophy

Question 36

A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• Weight loss
• Hypoglycemia RN ATI Capstone Adult Medical-Surg2
• Hypertension
• Hyperkalemia

Question 37

A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?

• It delivers a preset amount of inspiratory pressure at the beginning of each breath.
• It has a continuous adjustment feature that changes the airway pressure throughout the cycle.
• It delivers a preset amount of airway pressure throughout the breathing cycle. RN ATI Capstone Adult Medical-Surg2
• It delivers positive pressure at the end of each breath.

Question 38

A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching?

• “I should not wash my hair prior to the procedure.”
• “I will receive a sedative 1 hour before the procedure.”
• “I should avoid eating prior to the procedure.”
• “I will be exposed to flashes of light during the procedure.”

Question 39

A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

• Maintain a loose bandage on the residual limb.
• Turn the client from side to side once every 4 hr.
• Request a soft mattress for the client.
• Place the client prone for 20 min every 3 hr.

Question 40

A nurse is reviewing a client’s medical record prior to administering furosemide via IV bolus to a client who has heart failure. For which of the following findings should the nurse withhold the medication and notify the provider? RN ATI Capstone Adult Medical-Surg2

• Hypokalemia
• Hypernatremia
• Hypoglycemia
• Hypermagnesemia

Question 41

A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?

• Eat three large meals daily.
• Consume high-calorie foods.
• Limit caffeinated drinks to two per day.
• Drink fluids during meal time.

Question 42

A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A?

• A client who is hepatitis B positive.
• A client who had a kidney transplant in 1990.
• A client who has a history of intravenous street drug use.
• A client who has recently done volunteer work in a developing country.

Question 43

A nurse is instructing a client’s caregiver on how to position the client before administering tube feedings in the home. Which of the following statements by the caregiver demonstrates an understanding of the teaching?

• “I will allow them to assume a position of comfort.”
• “I will elevate the head of the bed 10 degrees.”
• “I will place them in a left side-lying position.”
• “I will sit them up in bed.”

Question 45

A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• Contact precautions
• Airborne precautions
• Droplet precautions
• Protective environment

Question 47

A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dysreflexia?

• Monitor bowel movement regularity.
• Use a fan to promote air circulation in the client’s room.
• Tuck the top bedsheet tightly around the client’s torso. RN ATI Capstone Adult Medical-Surg2
• Monitor for cerebrospinal fluid leakage.

Question 49

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?

• Pitting edema of bilateral lower extremities
• Hypoactive bowel sounds in all four quadrants
• Weight is the same as the day before
• Bilateral posterior lung sounds are diminished

Question 50

A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions should the nurse include?

• Initiate contact isolation precautions.
• Keep the client’s environment dark and quiet.
• Restrict the client’s fluid intake.
• Perform neurovascular assessments once a day.