CAPSTONE ATI NCLEX MEDICAL SURGICAL

CAPSTONE ATI NCLEX MEDICAL SURGICAL

ASSESSMENT 1 QUESTIONS AND CORRECT DETAILED

ANSWERS LATEST DOWNLOAD 2024/2025 BEST EXAM

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A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding

• PT 11.5 seconds
• aPTT 35 seconds
• Platelets 80,000
• RBC 4.0 million - CORRECT ANSWERS C Platelets 80,000

platelet range is 150,000-400,000

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

• Change the client's position every 2 hours
• Pad pressure points at the edges of the client's cervical collar
• Palpate the client's abdomen for bladder distention
• Assist the client with quad coughing - CORRECT ANSWERS 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

• Nasuea
• Hypothermia
• Dyspnea 1 / 3

• Bradycardia - CORRECT ANSWERS 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 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

• Hair loss on the scalp
• Sweating at the treatment site
• Altered taste sensations
• Intolerance to cold - CORRECT ANSWERS 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)

• Obtain pre-transfusion temperature
• Prime the IV tubing with lactated Ringer's
• Instruct an assistive personnel to monitor the client during the transfusion
• Verify the client's blood type with a second nurse
• Use a 20 gauge IV needle for venous access - CORRECT ANSWERS 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

• / 3

• 3.6 mg/dl
• 8 mg/dL
• 18.7 mg/dL
• 26 mg/dL - CORRECT ANSWERS 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)

• multiple irregular and variable waves at the baseline and irregular R to R intervals

• a rate of 140-180/min

• a tachycardia with no identifiable P wave and is determined to originate somewhere other than

the ventricles. Rate between 100-280/min

• a P wave for every QRS, rate is 60-100/min - CORRECT ANSWERS A.) multiple irregular and

variable waves at the baseline and irregular R to R intervals

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

• Obturator
• Hydrogen peroxide
• Sterile gloves
• Inner cannula - CORRECT ANSWERS A.) Obturator
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