ATI Capstone Adult Medical Surgical Assessment 1, Actual Exam Questions & Answers (Deeply Explained Answers)-1. A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Se...
ATI Capstone Adult Medical Surgical Assessment 1, Actual Exam Questions & Answers
(Deeply Explained Answers)
1. A nurse is caring for an adult client who asks about vaccinations against communicable diseases.
The nurse should inform the client that which of the following vaccines are available? (Select all
that apply)
Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine
Hepatitis C vaccine
Helicobacter pylori vaccine
Adult vaccines currently available to prevent contracting communicable diseases include those for
hepatitis A & B influenza and pneumonia. No vaccine is currently available for hep C/H. pylori = A, B, C
2. A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following
dietary modifications should the nurse include?
Provide a snack at bedtime
Choose decaffeinated coffee
Restrict intake of fried foods
Avoid drinking liquids with meals
The nurse should instruct the client to avoid fried foods, spicy foods, and acid-producing foods, such as
coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and black pepper can cause mucosal
damage. The nurse should instruct the client to avoid decaffeinated and caffeinated beverages and snacks
at bedtime, which can stimulate gastric acid secretion. A client with dumping syndrome, rather than
peptic ulcer should avoid liquids with meals = C
3. A nurse is caring for a client who is postoperative immediately following a pheochromocytoma
removal. Which of the following actions is the nurse’s priority?
Increase hydration
Monitor blood pressure
Measure urine output
Provide a calm environment
The greatest risk to this client is injury from hypertension due to the release of catecholamines during
surgery or hypotension from the sudden loss of catecholamines after the tumor has been removed.
Therefore, the priority intervention the nurse should take is to monitor the client's blood pressure = B
4. A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm
sounds. Which of the following actions should the nurse take?
Suction secretions from the endotracheal tube
Check the ventilator tubing connections Administer
intravenous sedation and analgesia
Reassure the client and instruct them not to bite on the tube
1
, A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or tube displacement
=B
5. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings
indicates the client might be experiencing a hemolytic transfusion reaction?
Hypertension
Report of urticaria
Distended neck veins
Report of chest pain
Chest pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include
headache, low back pain, and hypotension = D
6. A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings
should the nurse expect?
Dull percussion sounds
Increased anteroposterior chest diameter
Distended neck veins
Pitting edema
The consolidation that occurs with pneumonia will result in dull chest percussion over the involved lobes
=A
7. A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a
sealed radioactive implant. Which of the following information should the nurse include in the
teaching?
Place soiled linens in a lead container
Allow children who are over 10 years old to visit
Limit visitors to 1 hr per day
Wear a lead apron during care
The nurse should wear a lead apron at all times during care of a client who has a sealed radioactive
implant = D
8. A nurse is caring for a client who has a cervical spinal cord injury. Which of the following
interventions should the nurse include in the plan of care to prevent autonomic dysreflexia?
Monitor bowel movement regularity
Use a fan to promote air circulation to the client’s room
Tuck the top bedsheet tightly around the client’s torso
Monitor for cerebral spinal fluid leakage
Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic nervous system and
inadequate compensatory response by the parasympathetic nervous system. Common causes of
autonomic dysreflexia include distended bladder, fecal impaction, cold stress, tight clothing, and
2
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