ATI Capstone Medical Surgical assessment NCLEX Exam
with 43 Questions and Verified Answers
Graded A+ 2024/2025
1. A nurse on a med surg unit is caring for a group of clients.The nurse should notify the
rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse: B
2. A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids: B, C, E
3. A nurse in the emergency department is caring for a client who fell through the ice on
a pond and is unresponsive and breathing slowly. Which of the following actions
,should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids: A, C, D, E
4. A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of the
following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head: A
5. A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A. Perform defibrillation
, B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities: C
6. A nurse is caring for a client who is postprocedural following LP and re- ports
throbbing headache when sitting upright.Which of the following actions should the
nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exer- cises: B,
C, D
7. A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring.
The nurse should monitor the client for which of the following complications related to
the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension: B
8. A nurse is assessing a client for changes in the level of consciousness using the
GCS.The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
with 43 Questions and Verified Answers
Graded A+ 2024/2025
1. A nurse on a med surg unit is caring for a group of clients.The nurse should notify the
rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse: B
2. A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids: B, C, E
3. A nurse in the emergency department is caring for a client who fell through the ice on
a pond and is unresponsive and breathing slowly. Which of the following actions
,should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids: A, C, D, E
4. A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of the
following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head: A
5. A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A. Perform defibrillation
, B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities: C
6. A nurse is caring for a client who is postprocedural following LP and re- ports
throbbing headache when sitting upright.Which of the following actions should the
nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exer- cises: B,
C, D
7. A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring.
The nurse should monitor the client for which of the following complications related to
the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension: B
8. A nurse is assessing a client for changes in the level of consciousness using the
GCS.The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
