NCLEX ATI CAPSTONE MEDICAL SURGICAL ASSESSMENT
2025 | ALL QUESTIONS AND ANSWERS WITH
EXPLANATIONS | ALREADY GRADED A+ | VERIFIED
ANSWERS | NEWEST EXAM
A nurse is monitoring a client who is receiving moderate sedation
with midazolam. Which of the following findings requires
immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea ---------CORRECT ANSWER-----------------B) No
response to verbal stimuli
Using urgent vs non-urgent approach, this is the priority.
During moderate sedation, the pt should be able to provide a
response to questions and commands. No response to
verbal stimuli can indicate a loss or consciousness or
oversedation
A nurse is reviewing the laboratory findings for a client who has
heart failure and is taking furosemide. The nurse should identify
which of the following findings as an adverse effect of the
medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia ---------CORRECT ANSWER-----------------C.
Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through
the kidneys, causing an increased excretion of potassium.
Monitor for dysrhythmias
,A nurse is caring for a client who is in Buck's traction. Which of
the following actions should the nurse take? (select all that apply)
A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction bood
E. Assess the temperature of the affected extremity ---------
CORRECT ANSWER-----------------A, D, E
--
A, closely monitor the neurovascular integrity. Circulation
can be compromised from the fracture as well as the traction
device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well
as the traction device. Check and document color,
temperature, distal pulses, capillary refill, movement, and
sensation during neurovascular assessment. Monitor 6 P's:
pain, pallor, pulselessness, pressure, paresthesia, and
paralysis
A nurse is reviewing safety measures with the caregiver of a client
who has Alzheimer's disease. Which of the following instructions
should the nurse include in the teaching
A. Lock doors leading to stairways
B. Instruct the client not to use the stove
,C. Place a throw rug in front of the toilet
D. Provide a darkened room for the client to sleep ---------
CORRECT ANSWER-----------------A) Lock doors leading to
stairways
This pt is at an increased risk for falls d/t difficulty with
balance and an inability to recognize dangerous situations
due to brain damage from the disease
A nurse is developing a plan of care for a client who has
meningitis. Which of the following interventions should the nurse
include in the plan
A. Keep the client's room dark and quiet
B. Perform a vascular assessment for the client every 6 hr
C. Maintain the head of the client's bed at 15 degrees at all times
D. Place the client on contact precautions ---------CORRECT
ANSWER-----------------A) Keep the client's room dark and quiet
Meningitis often causes photophobia and phonophobia.
Reduce stimuli
A nurse is caring for a client who has a right subclavian central
venous catheter. Which reconnecting a new intravenous infusion
administration set, which of the following actions should the nurse
take
A. Ask the client to exhale slowly
B. Turn the client's head to the right
C. Place the client in a semi fowlers position
D. use aseptic technique ---------CORRECT ANSWER----------------
-D use aseptic technique
, Aseptic= sterile
Prevents central line related blood infections when
disconnecting and reconnecting the new set
A nurse is educating an older adult client about immunizations.
Which of the following immunizations should the nurse include in
the recommendation for the client
A. Recombinant herpes zoster
B. Human papillomavirus
C. Live attenuated influenza
D. Varicella ---------CORRECT ANSWER-----------------A)
Recombinant herpes zoster
Herpes zoster= shingles
Older adults can get either the live or recombinant herpes
zoster immunization
A nurse on a medical unit is planning care for a client who has
COPD. Which of the following actions should the nurse include in
the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal ------
---CORRECT ANSWER-----------------C) Provide the client with a
high protein diet
COPD needs a diet high in protein and calories. They should
eat freuqent, small meals and should avoid drinking fluids
prior to or during meals
2025 | ALL QUESTIONS AND ANSWERS WITH
EXPLANATIONS | ALREADY GRADED A+ | VERIFIED
ANSWERS | NEWEST EXAM
A nurse is monitoring a client who is receiving moderate sedation
with midazolam. Which of the following findings requires
immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea ---------CORRECT ANSWER-----------------B) No
response to verbal stimuli
Using urgent vs non-urgent approach, this is the priority.
During moderate sedation, the pt should be able to provide a
response to questions and commands. No response to
verbal stimuli can indicate a loss or consciousness or
oversedation
A nurse is reviewing the laboratory findings for a client who has
heart failure and is taking furosemide. The nurse should identify
which of the following findings as an adverse effect of the
medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia ---------CORRECT ANSWER-----------------C.
Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through
the kidneys, causing an increased excretion of potassium.
Monitor for dysrhythmias
,A nurse is caring for a client who is in Buck's traction. Which of
the following actions should the nurse take? (select all that apply)
A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction bood
E. Assess the temperature of the affected extremity ---------
CORRECT ANSWER-----------------A, D, E
--
A, closely monitor the neurovascular integrity. Circulation
can be compromised from the fracture as well as the traction
device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well
as the traction device. Check and document color,
temperature, distal pulses, capillary refill, movement, and
sensation during neurovascular assessment. Monitor 6 P's:
pain, pallor, pulselessness, pressure, paresthesia, and
paralysis
A nurse is reviewing safety measures with the caregiver of a client
who has Alzheimer's disease. Which of the following instructions
should the nurse include in the teaching
A. Lock doors leading to stairways
B. Instruct the client not to use the stove
,C. Place a throw rug in front of the toilet
D. Provide a darkened room for the client to sleep ---------
CORRECT ANSWER-----------------A) Lock doors leading to
stairways
This pt is at an increased risk for falls d/t difficulty with
balance and an inability to recognize dangerous situations
due to brain damage from the disease
A nurse is developing a plan of care for a client who has
meningitis. Which of the following interventions should the nurse
include in the plan
A. Keep the client's room dark and quiet
B. Perform a vascular assessment for the client every 6 hr
C. Maintain the head of the client's bed at 15 degrees at all times
D. Place the client on contact precautions ---------CORRECT
ANSWER-----------------A) Keep the client's room dark and quiet
Meningitis often causes photophobia and phonophobia.
Reduce stimuli
A nurse is caring for a client who has a right subclavian central
venous catheter. Which reconnecting a new intravenous infusion
administration set, which of the following actions should the nurse
take
A. Ask the client to exhale slowly
B. Turn the client's head to the right
C. Place the client in a semi fowlers position
D. use aseptic technique ---------CORRECT ANSWER----------------
-D use aseptic technique
, Aseptic= sterile
Prevents central line related blood infections when
disconnecting and reconnecting the new set
A nurse is educating an older adult client about immunizations.
Which of the following immunizations should the nurse include in
the recommendation for the client
A. Recombinant herpes zoster
B. Human papillomavirus
C. Live attenuated influenza
D. Varicella ---------CORRECT ANSWER-----------------A)
Recombinant herpes zoster
Herpes zoster= shingles
Older adults can get either the live or recombinant herpes
zoster immunization
A nurse on a medical unit is planning care for a client who has
COPD. Which of the following actions should the nurse include in
the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal ------
---CORRECT ANSWER-----------------C) Provide the client with a
high protein diet
COPD needs a diet high in protein and calories. They should
eat freuqent, small meals and should avoid drinking fluids
prior to or during meals
