ATI Capstone Med Surg Quiz Bank

1. a nurse is reviewing the ABG results of a client who the provider suspects

has metabolic acidosis. what would the nurse expect to see

Correct ANS- pH below 7.35

2. a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart

sound (S3), what should the nurse anticipate as the cause of these s/s

Correct ANS- HF

3. 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?

Correct ANS- 30mL

4. 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?

Correct ANS- administer sublingual nitroglycerin

(treat chest pain to reduce cardiac tissue damage)

5. a nurse is caring for pt who is experiencing ventricular tachycardia with a

pulse, the RRT is at the bedside. what electrical intervention should be used

to correct this dysrhythmia?

Correct ANS- synchronized cardioversion

(tx for afib, SVT, and v tach with a pulse)

6. a nurse is caring for an adult pt who is experiencing delayed wound healing,

which of the following interventions should the nurse take?

Correct ANS- 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)

7. a nurse is teaching a client who has pre-dialysis ESKD about diet, what

should be included?

Correct ANS- reduce intake of foods high in potassium

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(potassium clearance is impaired in ESKD)

8. 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?

Correct ANS- monitor the client for hypoglycemia

9. 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?

Correct ANS- check urine specific gravity

10.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?

Correct ANS- albuterol 3mL via nebulizer

11.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

Correct ANS- administer oxygen via face mask

12.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?

Correct ANS- unrelieved pain, pallor, pulselessness, numbness, pins and

needles sensation, swelling, tightness of the effected extremity

13.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

Correct ANS- lower the height of the solution container

14.a pt is diagnosed with left homonymous hemianopsia following a stroke,

what action should the nurse take?

Correct ANS- place the clients bedside table on the right side of the bed

15.a nurse is caring for a pt who is at risk for shock, what finding is the earliest

indicator that this complication is developing?

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Correct ANS- narrowing pulse pressure

16.a nurse is assessing a client who has hypokalemia as a result of n/v, and

diarrhea, what finding should the nurse expect

Correct ANS- weak, irregular pulse

17.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?

Correct ANS- avoid drinking alcohol

18.a nurse at an outpt surgery center is providing discharge teaching to a pt an

his spouse following surgical removal of a cataract, what should the nurse

include?

Correct ANS- the client should wear dark glasses while outdoors

19.a nurse is assessing a pt who has a puncture wound on his foot, what is a

manifestation of acute osteomylitis?

Correct ANS- localized erythema

20.a nurse is monitoring a pt who had a cerebral aneurysm rupture, what

finding should the nurse identify as a manifestation of increased intracranial

pressure Correct ANS- irritability

21.when caring for a pt with a chest tube the nurse notes continuous bubbling in

the chest tube water seal chamber, what does this indicate

Correct ANS- an air leak

22.a nurse is an ED is caring for a client who had a seizure and became

unresponsive after stating she had a sudden, severe headache, and vomiting,

the pts vital signs are as follows: BP 198/110, pulse of 82/min, RR of

24m/min, temp of 100.8F, what neuro disorders should the nurse suspect

Correct ANS- hemorrhagic stroke

23.a nurse is caring for a pt who is 2hr postoperative following a TURP, what

assessment should be an indication of a postoperative complication

Correct ANS- output of burgundy colored urine

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