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Ati capstone fundamentals exam
Total Questions : 48
Showing 10 questions, Sign in for moreA nurse is reviewing the laboratory report of a client who has been experiencing a fever for the last 3 days. Which of the following laboratory results indicates the client is experiencing fluid volume deficit?
1000:
Client reports severe abdominal pain. Vital signs obtained. Provider at bedside and labs drawn.
Client appears uncomfortable. Faint yellow hue to sclera. Breath sounds clear bilaterally. S1, S2 auscultated, no murmur. Client is holding abdomen. Abdomen mildly distended. Skin clammy. Reports pain as a 10 on a 0 to 10 numeric pain scale.
1100:
Client is nauseous and is vomiting and states pain is worsening. Rates pain as 8 on a 0 to 10 numeric pain scale. Notified provider, another dose of pain medication administered.
1000:
Temperature 38.2° C (100.9° F)
Heart rate 110/min
Respiratory rate 22/min
Blood pressure 98/58 mm Hg
1045:
WBC 16,500/mm3 (5,000 to 10,00mm3)
Serum amylase 680 units/L (30 to 220 units/L)
Serum lipase 300 units/L (0 to 160 units/L)
1030:
Impression: Pancreatitis
Maintain NPO status
Insert NG tube to low-intermittent suction
A nurse is caring for a client in the emergency department.
Complete the following sentence by using the lists of options.
To implement the provider's prescriptions the nurse should
Explanation
A. Insert the NG tube is the correct choice because the provider's order specifically states to "insert NG tube to low-intermittent suction." This intervention is a key part of managing acute pancreatitis, especially in clients experiencing nausea, vomiting, and abdominal distention.
B. Decompress the stomach and reduce vomiting is the correct reason because an NG tube helps remove gastric contents, reducing the stimulation of pancreatic enzyme secretion, which worsens inflammation. It also alleviates symptoms of nausea and vomiting, helping prevent further fluid loss and electrolyte imbalances.
Incorrect answers:
B. Administer prescribed antibiotics: There is no mention of an order for antibiotics in the provider’s prescriptions.
C. Perform abdominal assessment: While an abdominal assessment is always part of nursing care, it is not the primary action to implement the provider’s prescription. The nurse should still monitor for worsening symptoms, such as peritoneal signs or increasing distention.
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements Indicates an understanding of the teaching?
0800:
Client returned from a scheduled left-heart catheterization. The client is lying flat without complaints.
1000:
Client's partner reports that they noticed "blood on the sheets." Nurse observes there is bleeding around the catheter insertion site, and the pressure dressing has become dislodged. Nurse dons gloves and applies direct pressure to the wound. Provider notified, and a new hemostatic pressure dressing placed. Nurse removes gloves and notes a small amount of blood to the right upper hand.
0800:
- Temperature: 36.8°C (98.2°F)
- Heart rate: 75/min
- Respiratory rate: 18/min
- Blood pressure: 120/80 mm Hg
1000:
- Temperature: 36.8°C (98.2°F)
- Heart rate: 110/min
- Respiratory rate: 22/min
- Blood pressure: 100/60 mm Hg
A nurse is caring for a client on a medical-surgical unit.
Complete the following sentence by using the list of options.
The nurse should
Explanation
Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.
Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.
Incorrect answers;
i
Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.
Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.
ii
Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.
Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?
1130:
Client reports shortness of breath. Client states "my asthma is acting up." The client reports they have taken their rescue inhaler at home this morning without improvement in symptoms.
Client is alert, appears mildly uncomfortable. Mucous membranes moist. Diffuse wheezing auscultated throughout lung fields. S1, S2 auscultated, no murmur. Skin warm and dry. Vital signs obtained. Provider notified of findings, prescriptions obtained. Albuterol nebulizer administered along with methylprednisolone.
1200:
client re-evaluated following nebulizer treatment. Client ppears anxious, hand tremor present. Mucous membranes vanotic, clear rhinorrhea visible. Diffuse wheezing auscultated roughout lung fields. S1, S2 auscultated, no murmur. Skin arm and dry.
1130:
Temperature 37° C (98.6° F)
Heart rate 60/min
Respiratory rate 22/min
Blood pressure 138/82 mm Hg
Oxygen saturation 89% on 3L nasal cannula
1150
Temperature 37° C (98.6° F)
Heart rate 98/min
Respiratory rate 27/min
Blood pressure 168/90 mm Hg
Oxygen saturation 84% on 3L nasal cannula
A nurse is caring for a client in the emergency department.
Click to highlight the findings that indicate client's condition is worsening. To deselect a finding, click on the finding again.
Physical Exam:
1200:
Client re-evaluated following nebulizer treatment. Client appears anxious, hand tremor present. Mucous membranes cyanotic, clear rhinorrhea visible. Diffuse wheezing auscultated throughout lung fields. S1, S2 auscultated, no murmur. Skin warm and dry.
Temperature 37° C (98.6° F)
Heart rate 98/min
Respiratory rate 27/min
Blood pressure 168/90 mm Hg
Oxygen saturation 84% on 3L nasal cannula
Explanation
Oxygen Saturation: 84% on 3L nasal cannula
- The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.
Mucous Membranes Cyanotic
- Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.
Respiratory Rate: 27/min (Increased from 22/min)
- An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.
Client Appears Anxious
- Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.
1030:
Potassium Chloride 20 mEq PO STAT
1300:
Potassium Chloride 20 mEq PO daily
HCTZ 25 mg POQD
Amlodipine 10 mg POD
Clonidine 0.1 mg PO TID PRN blood pressure greater than 180 systolic
1000:
A client is admitted to start inpatient chemotherapy for breast cancer. The client has a past medical history of hypertension and breast cancer diagnosed 4 weeks ago.
1030:
The nurse reviews the provider's prescriptions.
A nurse is caring for a client on a medical-surgical unit.
Click to highlight the findings below of the prescriptions that the nurse should clarify with the provider prior to administering the medications. To deselect a finding, click on the finding again.
1300:
Potassium Chloride 20 mEq PO daily
HCTZ 25mg QD
Amlodipine 10 mg QOD
Clonidine .1 mg PO TID PRN blood pressure > 180 systolic
Explanation
When analyzing cues, the nurse should identify HCTZ, QD, QOD .1 mg, and >180mg systolic as error-prone abbreviations. Medications names, such as hydrochlorothiazide, should be spelled out. QD should be written as daily and QOD should be written as every other day. Decimal points should be written using a leading zero and greater than and less than should be written out rather than using symbols.
A 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 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 use to transfer the client?
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