ATI CAPSTONE MEDICAL SURGICAL ASSESSMENT 1
LATEST 2024-2025 ACTUAL EXAM 60 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to
heart failure. Which of the following statements by the client indicates an understanding of the teaching
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" - ANSWER-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
disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's
disease
A. Short term memory loss
B. misplacement of household items
C. Episodes of wandering
D. loss of mobility - ANSWER-C) Episodes of wandering
Wandering occurs in the moderate stage of AD
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 immediately
A. BUN 22 mg/dL
B. Sodium 134 mEq/L
C. Platelet count 18,000 mm
,D. WBC 4,500 mm - ANSWER-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
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 - ANSWER-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
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" - ANSWER-A
Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement,
which can increase intraocular pressure
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
A. "Maintain your dietary fat intake at 45% of your daily caloric intake"
B. "Obtain 15 minutes of sunlight exposure 3 times per week"
C. "Exercise for 30 minutes twice per week"
, D. "Decrease your fiber intake to less than 20 grams per day" - ANSWER-B) "Obtain 15 minutes of
sunlight exposure 3 times per week"
Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure
adequate vitamin D production
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 - ANSWER-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
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 inflammatory 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 - ANSWER-A. ) WBC count 14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms 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
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
LATEST 2024-2025 ACTUAL EXAM 60 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to
heart failure. Which of the following statements by the client indicates an understanding of the teaching
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" - ANSWER-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
disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's
disease
A. Short term memory loss
B. misplacement of household items
C. Episodes of wandering
D. loss of mobility - ANSWER-C) Episodes of wandering
Wandering occurs in the moderate stage of AD
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 immediately
A. BUN 22 mg/dL
B. Sodium 134 mEq/L
C. Platelet count 18,000 mm
,D. WBC 4,500 mm - ANSWER-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
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 - ANSWER-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
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" - ANSWER-A
Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement,
which can increase intraocular pressure
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
A. "Maintain your dietary fat intake at 45% of your daily caloric intake"
B. "Obtain 15 minutes of sunlight exposure 3 times per week"
C. "Exercise for 30 minutes twice per week"
, D. "Decrease your fiber intake to less than 20 grams per day" - ANSWER-B) "Obtain 15 minutes of
sunlight exposure 3 times per week"
Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure
adequate vitamin D production
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 - ANSWER-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
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 inflammatory 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 - ANSWER-A. ) WBC count 14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms 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
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
