Capstone ATI NCLEX Medical Surgical Assessment 1 Questions
with Answers and Explanations Complete Solutions, 100%
Correct | New Update | | Complete A+ Guide
Question 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?
Options:
A) "Hold the inhaler 2 inches away from your mouth"
B) "Inhale rapidly and deeply after activating the inhaler"
C) "Rinse the spacer with soap and water daily"
D) "Shake the inhaler vigorously prior to use"
Answer: D) "Shake the inhaler vigorously prior to use"
Explanation: Shaking the inhaler vigorously prior to use ensures that the medication is
properly mixed and dispersed. This is an essential step for proper administration. The
client should also be instructed to exhale completely before using the inhaler, place the
spacer in their mouth, activate the inhaler, and inhale slowly and deeply (not rapidly). The
spacer should be rinsed with warm water and allowed to air dry, not with soap and water
daily which can cause residue buildup.
Question 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?
Options:
A) Provide the client with a means of communication
B) Position the client in a supine position
C) Suction the client every 2 hours
D) Keep the client sedated at all times
Answer: A) Provide the client with a means of communication
Explanation: Clients receiving mechanical ventilation are unable to speak due to the
endotracheal or tracheostomy tube. Providing a means of communication (such as a
communication board, paper and pen, or electronic device) is essential to reduce anxiety
and allow the client to express needs. This is a priority nursing intervention for patient
safety and comfort. The client should be positioned in semi-Fowler's position to promote
ventilation, suctioning should be performed PRN (as needed) rather than on a fixed
schedule to prevent mucosal damage, and sedation should be used judiciously based on the
client's condition.
Question 3
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?
Options:
A) Serum sodium 155 mEq/L
B) Serum osmolality 310 mOsm/kg
C) Urine specific gravity 1.020
D) Hematocrit 55%
,Answer: C) Urine specific gravity 1.020
Explanation: Normal urine specific gravity ranges from 1.005 to 1.030. A value of 1.020 is
within normal range and indicates adequate hydration. In dehydration, urine specific
gravity is typically elevated (>1.030) due to concentrated urine as the kidneys attempt to
conserve water. As fluid replacement therapy corrects dehydration, urine specific gravity
normalizes. Serum sodium >145 mEq/L, serum osmolality >295 mOsm/kg, and elevated
hematocrit are all signs of dehydration that would improve with effective fluid
replacement.
Question 4
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?
Options:
A) Hemoglobin 14 g/dL
B) White blood cell count 10,000/mm³
C) Platelets 80,000/mm³
D) INR 1.0
Answer: C) Platelets 80,000/mm³
Explanation: Normal platelet count ranges from 150,000 to 400,000/mm³. A platelet
count of 80,000/mm³ is significantly below normal (thrombocytopenia) and indicates an
increased risk for bleeding. This is especially concerning in a postoperative patient who
may have surgical incisions and potential bleeding sites. Hemoglobin of 14 g/dL is normal,
WBC 10,000 is normal, and INR of 1.0 is normal (indicating normal coagulation). The nurse
should monitor the client for signs of bleeding and report this finding to the provider.
, Question 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?
Options:
A) Apply cervical collar
B) Administer pain medication
C) Assess muscle strength
D) Assist the client with quad coughing
Answer: D) Assist the client with quad coughing
Explanation: For a client with a cervical spinal cord injury, the priority is maintaining a
patent airway and adequate breathing. Cervical spinal cord injuries can impair respiratory
function due to paralysis of intercostal muscles and the diaphragm (in high cervical
injuries). Quad coughing is a technique used to assist clients with weak cough muscles to
clear secretions and prevent respiratory complications. While applying a cervical collar,
administering pain medication, and assessing muscle strength are important, airway and
breathing are the top priorities (ABCs).
Question 6
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 (TACO)?
with Answers and Explanations Complete Solutions, 100%
Correct | New Update | | Complete A+ Guide
Question 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?
Options:
A) "Hold the inhaler 2 inches away from your mouth"
B) "Inhale rapidly and deeply after activating the inhaler"
C) "Rinse the spacer with soap and water daily"
D) "Shake the inhaler vigorously prior to use"
Answer: D) "Shake the inhaler vigorously prior to use"
Explanation: Shaking the inhaler vigorously prior to use ensures that the medication is
properly mixed and dispersed. This is an essential step for proper administration. The
client should also be instructed to exhale completely before using the inhaler, place the
spacer in their mouth, activate the inhaler, and inhale slowly and deeply (not rapidly). The
spacer should be rinsed with warm water and allowed to air dry, not with soap and water
daily which can cause residue buildup.
Question 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?
Options:
A) Provide the client with a means of communication
B) Position the client in a supine position
C) Suction the client every 2 hours
D) Keep the client sedated at all times
Answer: A) Provide the client with a means of communication
Explanation: Clients receiving mechanical ventilation are unable to speak due to the
endotracheal or tracheostomy tube. Providing a means of communication (such as a
communication board, paper and pen, or electronic device) is essential to reduce anxiety
and allow the client to express needs. This is a priority nursing intervention for patient
safety and comfort. The client should be positioned in semi-Fowler's position to promote
ventilation, suctioning should be performed PRN (as needed) rather than on a fixed
schedule to prevent mucosal damage, and sedation should be used judiciously based on the
client's condition.
Question 3
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?
Options:
A) Serum sodium 155 mEq/L
B) Serum osmolality 310 mOsm/kg
C) Urine specific gravity 1.020
D) Hematocrit 55%
,Answer: C) Urine specific gravity 1.020
Explanation: Normal urine specific gravity ranges from 1.005 to 1.030. A value of 1.020 is
within normal range and indicates adequate hydration. In dehydration, urine specific
gravity is typically elevated (>1.030) due to concentrated urine as the kidneys attempt to
conserve water. As fluid replacement therapy corrects dehydration, urine specific gravity
normalizes. Serum sodium >145 mEq/L, serum osmolality >295 mOsm/kg, and elevated
hematocrit are all signs of dehydration that would improve with effective fluid
replacement.
Question 4
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?
Options:
A) Hemoglobin 14 g/dL
B) White blood cell count 10,000/mm³
C) Platelets 80,000/mm³
D) INR 1.0
Answer: C) Platelets 80,000/mm³
Explanation: Normal platelet count ranges from 150,000 to 400,000/mm³. A platelet
count of 80,000/mm³ is significantly below normal (thrombocytopenia) and indicates an
increased risk for bleeding. This is especially concerning in a postoperative patient who
may have surgical incisions and potential bleeding sites. Hemoglobin of 14 g/dL is normal,
WBC 10,000 is normal, and INR of 1.0 is normal (indicating normal coagulation). The nurse
should monitor the client for signs of bleeding and report this finding to the provider.
, Question 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?
Options:
A) Apply cervical collar
B) Administer pain medication
C) Assess muscle strength
D) Assist the client with quad coughing
Answer: D) Assist the client with quad coughing
Explanation: For a client with a cervical spinal cord injury, the priority is maintaining a
patent airway and adequate breathing. Cervical spinal cord injuries can impair respiratory
function due to paralysis of intercostal muscles and the diaphragm (in high cervical
injuries). Quad coughing is a technique used to assist clients with weak cough muscles to
clear secretions and prevent respiratory complications. While applying a cervical collar,
administering pain medication, and assessing muscle strength are important, airway and
breathing are the top priorities (ABCs).
Question 6
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 (TACO)?
