CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1 QUESTIONS AND ANSWERS

1 | Page
| | | | | |




CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 QUESTIONS
AND ANSWERS



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" - correct 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
| | | | | | | | |




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 - correct | | | | | | | | | |


answer- A.) Provide the client with a means of communication
| | | | | | | | | |

,2 | Page
| | | | | |




Use electronic tablet computer, programmable speech
| | | | |


generating device, alphabet board, pencil and paper, etc
| | | | | | | |




A nurse is caring for a client who is receiving IV fluid replacement
| | | | | | | | | | | |


therapy for dehydration. Which of the following laboratory results
| | | | | | | | |


indicates effectiveness of the treatment
| | | | |




A. Sodium 165 mEq/L | |




B. Potassium 5.2 mEq/L | |




C. Urine specific gravity 1.020 | | |




D. Hct 62% - correct answer- C Urine specific gravity 1.020
| | | | | | | | |




| Within the expected range of 1.005-1.030 | | | | |




A nurse is monitoring the laboratory findings for a client who is
| | | | | | | | | | |


postoperative following a total hip arthroplasty 6 hr ago. Which of
| | | | | | | | | | |


the following values indicates that the client has an increased risk
| | | | | | | | | | |


for bleeding
| |




A. PT11.5 seconds | |




B. aPTT 35 seconds | |




C. Platelets 80,000 |




D. RBC 4.0 million - correct answer- C Platelets 80,000
| | | | | | | |




| platelet range is 150,000-400,000 | | |

,3 | Page
| | | | | |




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 - correct answer- 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 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 - correct answer- C Dyspnea | | | | |




Dyspnea is an indication of possible transfusion associated | | | | | | |


circulatory overload, leading to hypertension, bounding pulses,
| | | | | | |

, 4 | Page
| | | | | |




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 - correct 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
| | | | | | | |