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ATI Capstone Med Surg

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1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse include in the plan? a) Ask the client to tilt their head back when swallowing. b) c) Administer liquids to the client using a syringe. d) Allow the client to rest for 10 min prior to eating. 2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red and there is warmth along the course of the vein. Which of the following actions should the nurse take? a) Initiate a new IV line below the original insertion site. b) c) Raise the head of the bed d) Obtain a culture from the area of the insertion site. 3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take? a) Document shiny, taut skin as an expected finding. b) c) Listen for 1 min before documenting absent bowel sounds d) Perform auscultation immediately after the client has consumed a meal. Have the client sit upright for 1 hr. following meals. Discontinue the infusion Perform palpitation after auscultation. lOMoARcPSD|15000798 4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as a part of the which of the following types of immunity? a) Passive immunity b) Active immunity c) Cellular immunity d) 5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify that which of the following is a risk factor that places older clients at an increased risk for developing infections? a) Overproduction of lymphocytes b) Elevated albumin levels c) d) Increased body fat 6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the following instructions should the nurse include in the teaching? a) Hold your breath for 6 seconds after inhaling the medication. b) c) Do not shake the medication in the inhaler d) Hold the inhaler 3 inches away from your mouth. 7. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect? a) Pulse oximetry reading of 95 % b) Decreased depth of respirations c) d) Respiratory rate of 16/min Acquired immunity Lowered immune system function Inhale the medication deeply for 5 seconds. Flaring of the nostrils lOMoARcPSD|15000798 8. A nurse is teaching a client about the correct use of a cane. Which of the following instruction should the nurse include in the teaching? (Selected all that apply) a) b) Hold the cane on the weaker side. c) d) Move the cane and stronger leg forward simultaneously e) 9. A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching? a) Increase in subcutaneous tissue b) Decrease in pigmentation c) Increase in moisture levels

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