ATI CAPSTONE MEDSURG LATEST VERSION GRADED A.

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse include in the plan? a) Ask the client to tilt their head ba... ck when swallowing. b) Have the client sit upright for 1 hr. following meals. c) Administer liquids to the client using a syringe. d) Allow the client to rest for 10 min prior to eating. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red and there is warmth along the course of the vein. Which of the following actions should the nurse take?a) Initiate a new IV line below the original insertion site. b) Discontinue the infusion c) Raise the head of the bed d) Obtain a culture from the area of the insertion site. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?a) Document shiny, taut skin as an expected finding. b) Perform palpitation after auscultation. c) Listen for 1 min before documenting absent bowel sounds d) Perform auscultation immediately after the client has consumed a meal. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as a part of the which of the following types of immunity? a) Passive immunity b) Active immunity c) Cellular immunity d) Acquired immunity 5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify that which of the following is a risk factor that places older clients at an increased risk for developing infections?a) Overproduction of lymphocytes b) Elevated albumin levels c) Lowered immune system function d) Increased body fat 6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the following instructions should the nurse include in the teaching? a) Hold your breath for 6 seconds after inhaling the medication. b) Inhale the medication deeply for 5 seconds. c) Do not shake the medication in the inhaler d) Hold the inhaler 3 inches away from your mouth. 7. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect? a) Pulse oximetry reading of 95 % b) Decreased depth of respirations c) Flaring of the nostrils d) Respiratory rate of 16/min a) Numerical pain scale b) Verbal description c) Faces pain scale d) Behavioral indicators 18. A nurse in an emergency department is monitoring the hydration status of a client who is receiving oral rehydration. Which of the following findings should the nurse identify as requiring further interventions? a) Heart rate 120/min b) BP 121/74 mm Hg c) Temperature 37 C (100 F) d) Urine specific gravity 1. 19 nurse in a provider’s office is assessing the motor skill developmetoddler during a well child visit. Which of the following gross motor skills should the nurse nt of a 15 month old expect? a) Takes several steps on tip toes b) Walks without assistance using a wide stance c) Has an accentuated cervical curvature when standing d) Stands with the feet turned slightly inward. 20. A nurse is teaching a group of parents and guardians about safety risks for adolescents. Which of the following statements should the nurse include in the teaching? a) “Exploring the environment commonly leads to injuries for this age group.” b) “Most injuries sustained during this time of life are caused by developing motor skills.” c) “At this age, peer influence to participate in high -risk behaviors can lead to injury” d) The risk for injuries sustained during this age are often a result of a changes in cognitive function” 21 nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the following actions should the nurse take?a) Ask the client to describe their feelings b) Discuss the competency of the surgeon with the client c) Inform the client that others have had the procedure without problems. d) Ask the client why they are experiencing anxiety. 22. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching? a) “I need to have an attorney sign my advance directives” b) “I have a living will that outlines my wishes if I am unable to make decisions” c) “I must have a family member appointed to make my health care decisions” d) “I will need to sign a document stating that I want to be resuscitated if I required CPR.” 23 nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable? (Select all that apply) a) Smoking b) Alcohol consumption c) Inflammatory bowel disease d) High-fat diet e) Colorectal polyps 27 nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client’s history and assessment? a) Insert an intravenous catheter to begin fluid therapy b) Develop actions to address the client’s manifestations c) Identify the client’s needs d) Determine the effectiveness of treatment. 28 nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take? a) Mix the medications together and administer through the NG tube. b) Crush the sublingual medication into powder form c) Dissolve crushed tablet medications in sterile water. d) Flush the tube with 5 ml saline between each medication. 29 nurse is preparing to perform a sterile dressing change for a client who has surgical wound. Which of the following actions should the nurse take to prevent contamination during thedressing change? a) Remove a piece of the new dressing that falls 5cm(2in) from the edge of the sterile field during the dressing change. b) Begin the dressing change by applying sterile gloves and removing the existing dressing c) Restart the procedure if the sterile solution splashes onto the sterile flied when pouring the solution into the dressing tray d) Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. 31 nurse is reviewing the health history of an older adult client who has a hip fracture. The nurse should identify that which of the following findings places the client at risk for developing a pressure injury? a) Osteoporosis b) Urinary incontinence c) Macular degeneration d) Psoriasis 32 nurse is performing a focused assessment for a client who has dysrhythmia. Which of the following indicates ineffective cardiac contractions? a) Carotid bruit b) Heart murmur c) Pulse deficit d) Bounding radial pulse 33 nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse to transfer the client?a) A stand-assist lift b) A footboard c) A slide boards d) A mechanical lift with a full body sling 34. A charge nurse is making assignments for the upcoming shift. Which of the following client assignments should the charge nurse assign to a licensed practical nurse (LPN) a) A client who is to received moderate (conscious) sedation. Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection 3. A nurse is caring for a client who has syndrome of inappropriate The surgical site will heal in 3 to 4 weeks after surgery antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1. 020 Sodium 119 mEq/L No tiene pregunta 4. A nurse is teaching a client About fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? Your provider will use stool from your digital rectal examination to perform the test Your provider will prescribe a stimulant laxative prior to the You should begin annual fecal occult blood testing for colorectaprocedure tol cancer screening at 40 years old 5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol Pancuronium 6. A nurse is reviewing the medical record of a client who has unstable angina. Which of the findings should the nurse report to the provider? Breath Sounds Temperature 7. A nurse is caring for a client eho has burn injuries cconcerned about thei altered appearance .Which of the followinovering their upper body and is g statements should the nurse make? No aparece la respuesta 8. Anurse is developing a plan of care for a client who will following surgical repair of the cervical spine .Which of the following interventions be placed in halo traction should the nurse include in the plan? Inspect thi pin site every 48 hr Monitor the client skin under the alo vest. Ensure two personnel hold the halo device when repositioning the client. 9. A nurse is caring for a client who has a traumatic braifollowing finding should indicate to the nurse the needn injury. Which of the for inmediate intervention ¿ Axillary temperature 37 C (99F)Apical pulse 100/min Respiratory rate 30/min 10. A nurse is assessing a client who has meningitis. Thethe following finding as a positive Kerning s sign? nurse should edentify which of After stroking the lateral área of the foot , the clients toesAfter hip flexion, the client is unable to extend their leg complety contract and draw together. without pain 11. A nurse is providing discharge teaching to a client whofor furosemide 20 mg PO two time daily. Which of the followin has heart failure an a prescriptiong instructions should the nurse include in the teaching? Monitor for increased blood pressure Increase intake of high-potassium foods Expect an increase in swelling in the hands and feet. 12. A nurse is providing discharge instructions to a client wfollowing statements by the client demostrates an understho has GERD. Which of the anting of the teaching? I should take my medicine with orange juice .Abedtime snack will prevent heartburn Initiate insulin drip Monitor blood glucose levels Continue regular diet as tolerated MantainManage acute painNPO status until pain free [Show More]

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