ATI Capstone Med Surg Exam
A nrse is reviewing the ABG results of a patient who the provider suspects
has metabolic acidosis. what would the nrse expect to see
Correct answer- pH below 7.35
A pt is experiencing SOB, fatigue, JVD, the nrse auscultates a third heart
sound (S3), what should the nrse anticipate as the cause of these s/s
Correct answer- HF
A nrse 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
nrse administer per dose?
Correct answer- 30mL
A nrse is caring for a pt in the ED who was just admitted with chest pain,
possible acute coronary syndrome. what should the nrse do first?
Correct answer- administer sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
A nrse 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 answer- synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
A nrse is caring for an adult pt who is experiencing delayed wound healing,
which of the following interventions should the nrse take?
Correct 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 nrse is teaching a patient who has pre-dialysis ESKD about diet, what
should be included?
Correct answer- reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
A nrse is caring for a patient who has T1DM, the nrse misread the patient'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 patient's
breakfast, what action is the nrse's priority?
Correct answer- monitor the patient for hypoglycemia
A nrse is planning care for a pt who has a new diagnosis of DI, which of the
following interventions should the nrse include in the plan of care?
Correct answer- check urine specific gravity
A nrse 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 answer- albuterol 3mL via nebulizer
A nrse is caring for a female patient 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 answer- administer oxygen via face mask
A nrse is caring for a pt following repair of a fracture, what finding should
alert the nrse that the pt is experiencing compartment syndrome?
Correct answer- unrelieved pain, pallor, pulselessness, numbness, pins and
needles sensation, swelling, tightness of the effected extremity
A nrse is administering a tap water enema to a pt who is constipated, during
the administration of the enema, the patient states he is having abdominal
cramps, what action should the nrse take to relieve the patient's comfort
Correct answer- lower the height of the solution container
A pt is diagnosed with left homonymous hemianopsia following a stroke,
what action should the nrse take?
Correct answer- place the patients bedside table on the right side of the bed
A nrse is caring for a pt who is at risk for shock, what finding is the earliest
indicator that this complication is developing?
Correct answer- narrowing pulse pressure
A nrse is assessing a patient who has hypokalemia as a result of n/v, and
diarrhea, what finding should the nrse expect
Correct answer- weak, irregular pulse
A nrse is providing teaching for a patient who has experienced an acute
episode of gastritis, what instruction should the nrse include in the teaching?
Correct answer- avoid drinking alcohol