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" - ANS 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 - ANS 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 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% - ANS 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. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - ANS C Platelets 80,000
platelet range is 150,000-400,000
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 - ANS 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 - ANS 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 - ANS 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 - ANS 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 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
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" - ANS 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 - ANS 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 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% - ANS 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. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - ANS C Platelets 80,000
platelet range is 150,000-400,000
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 - ANS 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 - ANS 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 - ANS 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 - ANS 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 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
