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Capstone ATI NCLEX Medical Surgical Assessment
1.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": 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
2.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: A.) Provide the client with a means of communication
Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc
3.A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the
following laboratory results indicates effective- ness of the treatment
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A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.
D. Hct 62%: C Urine specific gravity 1.020 Within the
expected range of 1.005-1.
4.A nurse is monitoring the laboratory findings for a client who is postoper- ative following a total hip
arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,
D. RBC 4.0 million: C Platelets 80,000 platelet range is
5.A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of
the following interventions is the nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing: D Assist the client with quad coughing 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
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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: 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
9.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: 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
10.A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify
as atrial fibrillation
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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: A.) multiple irregular and variable waves at the baseline and irregular
R to R intervals
11.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: A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or decannu- lation 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
12.A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2 days ago.
Which of the following statements should the nurse use to assess how the client is coping with this change in their
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D. Nausea: 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
15.A nurse is reviewing the laboratory findings for a client who has heart fail- ure 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: C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias
16.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: A, D, E
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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, pulse- lessness, pressure, paresthesia, and paralysis
17.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: 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
18.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
B. Perform a vascular assessment for the client every 6 hr
10 / 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: C )
Subtract the amount of irrigation solution from the in- dwelling urinary catheter output Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag
22.A nurse is administering epinephrine IV to a client who is having an ana- phylactic 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: 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
23.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
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24.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": 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
25.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 recommen- dations 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"
C. "Protect exposed skin with an over the counter sunscreen"
D. "Wear form sitting clothing when going outside": A) "Try to avoid sun expo- sure by waiting until after sunset
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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: 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.
29. 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: 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
30.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
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A. "I will limit my dietary sodium intake to 4 grams per day"
B. "I should weigh myself once a week"
C. "I plan to wait 2 hours after eating to take my walk"
D. "I will take my diuretic before going to bed at night": C
To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise
A, limit sodium to 2-3g per day to prevent fluid retention in a heart healthy diet B, weigh daily! Report a weight gain of more than 1.4kg (3lb) in 1 day or more than 2.3 kg (5lb) per week D, take diuretics in the morning to avoid having to get up during the night to void
33.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 imme- diately
A. BUN 22 mg/dL
B. Sodium 134 mEq/L
C. Platelet count 18,000 mm
D. WBC 4,500 mm: 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
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34.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: 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
35.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": A
Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure
36.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
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37.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
C. Gabapentin
D. Lidocaine: C) Gabapentin
phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain
38.A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the
following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflam- matory response syndrome (SIRS)?
A. WBC count 14,000/mm
B. Platelets 110,000/ mm
C. Lactic acid 19 mg/dL
D. C reactive protein 2.8 mg/L: A. ) WBC count 14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS over- whelms the body's defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow's ability to produce neutrophils and WBCs, the WBC count can become extremely low
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39.A nurse is caring for a client who is receiving brachytherapy. Which of the following actions should the
nurse take?
A. Limit visitation time to 2 hr per day, per visitor
B. Wear a dosimeter film badge when caring for the client
C. Open the door toe the client's room when visitors are present
D. Double bag bed linens and remove them daily from the client's room: B )
Wear a dosimeter film badge when caring for the client the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation
40.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: 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
41.A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is
