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ATI NCLEX MEDICAL SURGICAL CAPSTONE
ASSESSMENT 1/ CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 EXAM QUESTIONS
WITH VERIFIED ANSWERS NEW UPDATED EXAM
2 025/2026 LATEST
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr -- ANSWER--A.) Provide the client with a means of communication Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18.7 mg/dL D. 26 mg/dL -- ANSWER--D 26 mg/dL
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation (cannot insert pictures, read description) A. multiple irregular and variable waves at the baseline and irregular R to R intervals B. a rate of 140-180/min C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min D. a P wave for every QRS, rate is 60-100/min -- ANSWER--A.) multiple irregular and variable waves at the baseline and irregular R to R intervals A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include A. "Wait at least 5 minutes between puffs from the same inhaler" B. "Breathe in rapidly when inhaling the medication" C. "Clean the plastic inhaler cap weekly with cold water" D. "Shake the inhaler vigorously prior to use" -- ANSWER--D .) "Shake the inhaler vigorously prior to use" Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily
The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing) A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia -- ANSWER--C Dyspnea Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy A. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold -- ANSWER--C Altered taste sensations Altered taste is a result of the release of metabolites by dead cells A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature B. Prime the IV tubing with lactated Ringer's C. Instruct an assistive personnel to monitor the client during the transfusion D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access -- ANSWER--A, D, E A, complete assessment prior to transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client's room upon admission A. Obturator B. Hydrogen peroxide C. Sterile gloves D. Inner cannula -- ANSWER--A.) Obturator The obturator can be inserted in the stoma in the even of dislodgment or decannulation to maintain an airway until a new trach tube can be placed. For the first 72 hr following the insertion of a trach, dislodgement or decannulation is considered an emergency
C. Occasional premature ventricular contractions (PVCs) D. Nausea -- ANSWER--B) No response to verbal stimuli using urgent vs non-urgent approach, this is the priority. During moderate sedation, the pt should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss or consciousness or oversedation A nurse is reviewing the laboratory findings for a client who has heart failure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication A. Sodium 142 mEq/L B. Metabolic acidosis C. Potassium 3.2 mEq/L D. Hypoglycemia -- ANSWER--C. Potassium 3.2 mEq/L Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (select all that apply) A. Monitor peripheral pulses in the affected extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every 24 hrs D. Examine the skin under the traction bood E. Assess the temperature of the affected extremity -- ANSWER--A, D, E
A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device D, monitor skin integrity at least every 8 hr E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure, paresthesia, and paralysis A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching A. Lock doors leading to stairways B. Instruct the client not to use the stove C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep -- ANSWER--A) Lock doors leading to stairways This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet
herpes zoster= shingles Older adults can get either the live or recombinant herpes zoster immunization A nurse is caring fro a client who has continuous bladder irrigation following a transurthral resection of the prostate (TURP). Which of he following actions should the nurse take A. Place the indwelling urinary catheter tubing so it lies freely between the client's legs B. Irrigate the indwelling urinary catheter using sterile water C. Subtract the amount of irrigation solution from the indwelling urinary catheter output D. Flush the indwelling urinary catheter with 30mL of irrigation solution to clear an obstruction -- ANSWER--C ) Subtract the amount of irrigation solution from the indwelling urinary catheter output Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag A nurse is administering epinephrine IV to a client who is having an anaphylactic reaction. Which of the following findings should the nurse identify as a therapeutic response to the medication A. Hypoglycemia B. Thickened bronchial secretions C. Regular heart rate with hypotension D. Non itchy skin wheals -- ANSWER--D) Non itchy skin wheals A pt in anaphylactic shock can experience intensely itchy skin with wheals or hives that can merge to form large red blotches. Epi blocks the release of histamine and decreases erythema, angioedema, and hives
A nurse is assisting in selecting foods for lunch with a client who has diverticulosis. Which of the following foods should the nurse recommend as the best source of fiber A. 1 slice of rye bread B. 1/2 cup cooked navy beans C. 1/2 cup cooked asparagus D. 1/2 cup watermelon -- ANSWER--B) 1/2 cup cooked navy beans navy beans contain 5g of fiber per 1/2 cup A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of the teaching A. "I will wear my graduated compression stockings while sleeping" B. "I will elevate my legs for 10 minutes 3 times per day" C. "I will limit the time I spend sitting down during the day" D. "I will cross my legs at my knees when sitting" -- ANSWER--C) "I will limit the time I spend sitting down during the day" Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommendations should the nurse include in the teaching? A. "Try to avoid sun exposure by waiting until after sunset to go outdoors" B. "Gently was the irradiated area to remove the markings before going outside"
A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10 D. Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min -- ANSWER--D) Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation and can indicate respiratory failure or shock, especially in pt who is postop. A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan A. Suction the client's airway every 4 hours B. Limit the client's fluid intake to control secretions C. Provide the client with a high protein diet D. Administer the client's bronchodilator following each meal -- ANSWER--C) Provide the client with a high protein diet
COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals A nurse is administering parenteral nutrition to a client who has a history of heart failure. Which of the following manifestations indicates to the nurse that the client is experiencing fluid overload A. hypotension B. flattened neck veins C. nocturia D. weight loss -- ANSWER--C when the client is recumbent, the extracellular fluid enters the vascular system and increases the blood volume filtering through the kidneys, which increases urine production -- A, hypertension indicates fluid overload in a pt with heart failure B, distended neck veins indicates fluid overload in a pt with heart failure D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure A nurse is teaching the caregiver of a client who has mild alzheimer's disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's disease
A nurse is reviewing the laboratory reports of a client who has cirrhosis. Which of the following results should the nurse report to the provider immediately A. BUN 22 mg/dL B. Sodium 134 mEq/L C. Platelet count 18,000 mm D. WBC 4,500 mm -- ANSWER--C) Platelet count 18,000 mm The greatest risk to this client is injury from hemorrhage, and 18,000 is critically lower than the range of 150,000-400,000. A level <20,000 is a critical value representing thrombocytopenia and the potential for spontaneous bleeding A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first A. Verify the label on the blood product with 2 client identifiers B. Check the client's medical record to verify the provider's prescription C. Flush the blood tubing with 0.9% sodium chloride D. Instruct the client to report itching or shortness of breath -- ANSWER--B) Check the client's medical record to verify the provider's prescription The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure
A. "Avoid straining to have a bowel movement" B. "Avoid lying on your right side" C. "Avoid lifting objects that weigh more than 5 pounds" D. "Avoid sleeping with your head elevated" -- ANSWER--A Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure A nurse is providing teaching about health promotion activities to an older adult client. Which of the following recommendations should the nurse include in the teaching A. "Maintain your dietary fat intake at 45% of your daily caloric intake" B. "Obtain 15 minutes of sunlight exposure 3 times per week" C. "Exercise for 30 minutes twice per week" D. "Decrease your fiber intake to less than 20 grams per day" -- ANSWER--B) "Obtain 15 minutes of sunlight exposure 3 times per week" Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure adequate vitamin D production A nurse is caring for a client who has an above the knee amputation related to trauma and is experiencing phantom limb pain. Which of the following medications should the nurse administer to treat the client's pain? A. Meloxicam B. Cyclobenzaprine
the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation A nurse is panning care for a client who has been newly diagnosed with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care A. Encourage liquid nutritional supplements B. Administer opioid medications via a PCA C. Assess for signs of hypercalcemia D. Administer hypotonic IV fluids -- ANSWER--B) Administer opioid medications via a PCA pain mangement is important in the care of a client who has pancreatitis. Clients are most often started on opioid medication via PCA in the early stages of pancreatitis to mange pain A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is receiving heparin therapy by continuous IV infusion. Which of the following prescriptions should the nurse anticipate for an aPTT of 110 seconds A. Increase the rate of the heparin infusion B. Stop the heparin infusion C. Administer vitamin K to the client D. Administer atropine to the client -- ANSWER--B) Stop the heparin infusion Therapeutic range of aPTT for client on heparin is 1.5-2.5 times the normal value. A value greater than 2.5 times the expected reference range of 20-40 seconds is critical! If the aPTT is > 100 seconds, anticipate a prescription to stop or decrease the heparin infusion rate
A nurse in the emergency department is caring for a client who has a traumatic brain injury (TBI). Which of the following assessment findings should the nurse recognize as a late manifestation of increased intracranial pressure (ICP) (select all that apply) A. Tachypnea B. Increased restlessness C. Bradycardia D. Asymmetric pupils E. Widened pulse pressure -- ANSWER---Bradycardia -Asymmetric pupils -Widened pulse pressure A nurse is caring for a client who has end stage liver disease and an active upper GI bleed. After inserting an NG tube, which of the following findings should the nurse expect A. Bright red drainage B. Dark brown drainage C. Off white drainage D. Greenish yellow drainage -- ANSWER--A. Bright red drainage Red NG output indicates the client has an active upper GI bleed A nurse is educating a group of clients about menopause. Which of the following information should the nurse include
