ATI CAPSTONE MED SURG
- A nurse is reviewing the ABG results of a client who the provider suspects has
metabolic acidosis. what would the nurse expect to see
Answer: pH below 7.35 - A patient is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart
sound (S3), what should the nurse anticipate as the cause of these signs and symptoms
Answer: 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?
Answer: 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?
Answer: administer sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage) - A nurse is caring for patient who is experiencing ventricular tachycardia with a pulse,
the RRT is at the bedside. what electrical intervention should be used to correct this
dysrhythmia?
Answer: 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?
Answer: 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?
Answer: 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?
Answer: 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?
Answer: 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?
Answer: 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
Answer: 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?
Answer: 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
Answer: lower the height of the solution container - A patient is diagnosed with left homonymous hemianopsia following a stroke, what
action should the nurse take?
Answer: place the clients bedside table on the right side of the bed - A nurse is caring for a patient who is at risk for shock, what finding is the earliest
indicator that this complication is developing?
Answer: 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
Answers: 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?
Answer: avoid drinking alcohol