ATI Capstone Med Surg, Capstone Med Surg Assessment 1

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ATI Capstone Med Surg, Capstone Med Surg Assessment 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 - pH below ... 7.35 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 - HF 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? - 30mL 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? - administer sublingual nitroglycerin (treat chest pain to reduce cardiac tissue damage) 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? - synchronized cardioversion (tx for afib, SVT, and v tach with a pulse) a nurse is caring for an adult pt who is experiencing delayed wound healing, which of the following interventions should the nurse take? - 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 nurse is teaching a client who has pre-dialysis ESKD about diet, what should be included? - reduce intake of foods high in potassium (potassium clearance is impaired in ESKD) 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? - monitor the client for hypoglycemia 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? - check urine specific gravity 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? - albuterol 3mL via nebulizer 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 - administer oxygen via face mask 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? - unrelieved pain, pallor, pulselessness, numbness, pins and needles sensation, swelling, tightness of the effected extremity 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 - lower the height of the solution container a pt is diagnosed with left homonymous hemianopsia following a stroke, what action should the nurse take? - place the clients bedside table on the right side of the bed a nurse is caring for a pt who is at risk for shock, what finding is the earliest indicator that this complication is developing? - narrowing pulse pressure a nurse is assessing a client who has hypokalemia as a result of n/v, and diarrhea, what finding should the nurse expect - weak, irregular pulse 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? - avoid drinking alcohol 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? - the client should wear dark glasses while outdoors [Show More]

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