ATI Capstone Med Surg Exam| 120
Questions and Verified Answers 2025
A nurse is reviewing the ABG results of a client who the provider suspects has metabolic
acidosis. What would the nurse expect to see?
Correct Answer: pH below 7.35
Explanation: Metabolic acidosis is characterized by a pH below 7.35 due to an excess of
acid or a loss of bicarbonate. The body compensates by decreasing PaCO2 (respiratory
compensation).
A pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3).
What should the nurse anticipate as the cause of these s/s?
Correct Answer: HF (Heart Failure)
Explanation: Symptoms like SOB, fatigue, JVD, and an S3 heart sound are classic signs
of heart failure, particularly left-sided heart failure.
A nurse is administering potassium chloride elixir 40 mEq divided into 2 equal doses every
12 hours. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose?
Correct Answer: 30 mL
Explanation: Each dose is 20 mEq (40 mEq ÷ 2). Using the concentration 6.7 mEq/5
mL, the calculation is (20 mEq ÷ 6.7 mEq) × 5 mL = 30 mL.
A nurse is caring for a pt in the ED who was just admitted with chest pain, possible acute
coronary syndrome. What should the nurse do first?
Correct Answer: Administer sublingual nitroglycerin
Explanation: Sublingual nitroglycerin is the first-line treatment for chest pain in acute
coronary syndrome to relieve ischemia and reduce cardiac tissue damage.
A nurse is caring for a pt who is experiencing ventricular tachycardia with a pulse. The
RRT is at the bedside. What electrical intervention should be used to correct this
dysrhythmia?
, Correct Answer: Synchronized cardioversion
Explanation: Synchronized cardioversion is used for ventricular tachycardia with a pulse
to restore normal rhythm without causing further harm.
A nurse is caring for an adult pt who is experiencing delayed wound healing. Which of the
following interventions should the nurse take?
Correct Answer: Monitor serum albumin levels and notify the provider if below 3.5
g/dL
Explanation: Low serum albumin indicates protein deficiency, which impairs wound
healing and increases infection risk.
A nurse is teaching a client who has pre-dialysis ESKD about diet. What should be
included?
Correct Answer: Reduce intake of foods high in potassium
Explanation: In ESKD, potassium clearance is impaired, leading to hyperkalemia, which
can cause life-threatening cardiac dysrhythmias.
A nurse is caring for a client who has T1DM. The nurse misread the client's morning BG
level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for
a reading over 200 mg/dL before the client's breakfast. What action is the nurse's priority?
Correct Answer: Monitor the client for hypoglycemia
Explanation: Administering too much insulin can lead to hypoglycemia, which is a
medical emergency.
A nurse is planning care for a pt who has a new diagnosis of DI. Which of the following
interventions should the nurse include in the plan of care?
Correct Answer: Check urine specific gravity
Explanation: In DI, urine specific gravity is low due to the inability to concentrate urine.
A nurse is caring for a pt admitted with wheezing and coughing due to an allergic reaction
to a newly prescribed medication. What medication should be administered first?
Correct Answer: Albuterol 3 mL via nebulizer
Explanation: Albuterol is a bronchodilator that relieves wheezing and bronchospasm
caused by an allergic reaction.
, A nurse is caring for a female client in the ED who reports SOB and pain in the lung area.
She states that she started taking BC pills 3 weeks ago and that she smokes. Her heart rate
is 110/min, RR 40/min, and BP 140/80. Her ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3
20, SaO2 86%. What is the priority of nursing interventions?
Correct Answer: Administer oxygen via face mask
Explanation: The ABG results indicate respiratory alkalosis and hypoxemia, likely due
to a pulmonary embolism (PE). Oxygen is the priority to improve oxygenation.
A nurse is caring for a pt following repair of a fracture. What finding should alert the
nurse that the pt is experiencing compartment syndrome?
Correct Answer: Unrelieved pain, pallor, pulselessness, numbness, pins and needles
sensation, swelling, tightness of the affected extremity
Explanation: These are the classic signs of compartment syndrome, a medical
emergency requiring immediate intervention.
A nurse is administering a tap water enema to a pt who is constipated. During the
administration of the enema, the client states he is having abdominal cramps. What action
should the nurse take to relieve the client's comfort?
Correct Answer: Lower the height of the solution container
Explanation: Lowering the height of the container slows the flow of the enema, reducing
cramping.
A pt is diagnosed with left homonymous hemianopsia following a stroke. What action
should the nurse take?
Correct Answer: Place the client's bedside table on the right side of the bed
Explanation: Left homonymous hemianopsia causes loss of vision in the left visual field.
Placing items on the right side ensures the client can see them.
A nurse is caring for a pt who is at risk for shock. What finding is the earliest indicator that
this complication is developing?
Correct Answer: Narrowing pulse pressure
Explanation: Narrowing pulse pressure (difference between systolic and diastolic BP) is
an early sign of shock due to decreased cardiac output.
Questions and Verified Answers 2025
A nurse is reviewing the ABG results of a client who the provider suspects has metabolic
acidosis. What would the nurse expect to see?
Correct Answer: pH below 7.35
Explanation: Metabolic acidosis is characterized by a pH below 7.35 due to an excess of
acid or a loss of bicarbonate. The body compensates by decreasing PaCO2 (respiratory
compensation).
A pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3).
What should the nurse anticipate as the cause of these s/s?
Correct Answer: HF (Heart Failure)
Explanation: Symptoms like SOB, fatigue, JVD, and an S3 heart sound are classic signs
of heart failure, particularly left-sided heart failure.
A nurse is administering potassium chloride elixir 40 mEq divided into 2 equal doses every
12 hours. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose?
Correct Answer: 30 mL
Explanation: Each dose is 20 mEq (40 mEq ÷ 2). Using the concentration 6.7 mEq/5
mL, the calculation is (20 mEq ÷ 6.7 mEq) × 5 mL = 30 mL.
A nurse is caring for a pt in the ED who was just admitted with chest pain, possible acute
coronary syndrome. What should the nurse do first?
Correct Answer: Administer sublingual nitroglycerin
Explanation: Sublingual nitroglycerin is the first-line treatment for chest pain in acute
coronary syndrome to relieve ischemia and reduce cardiac tissue damage.
A nurse is caring for a pt who is experiencing ventricular tachycardia with a pulse. The
RRT is at the bedside. What electrical intervention should be used to correct this
dysrhythmia?
, Correct Answer: Synchronized cardioversion
Explanation: Synchronized cardioversion is used for ventricular tachycardia with a pulse
to restore normal rhythm without causing further harm.
A nurse is caring for an adult pt who is experiencing delayed wound healing. Which of the
following interventions should the nurse take?
Correct Answer: Monitor serum albumin levels and notify the provider if below 3.5
g/dL
Explanation: Low serum albumin indicates protein deficiency, which impairs wound
healing and increases infection risk.
A nurse is teaching a client who has pre-dialysis ESKD about diet. What should be
included?
Correct Answer: Reduce intake of foods high in potassium
Explanation: In ESKD, potassium clearance is impaired, leading to hyperkalemia, which
can cause life-threatening cardiac dysrhythmias.
A nurse is caring for a client who has T1DM. The nurse misread the client's morning BG
level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for
a reading over 200 mg/dL before the client's breakfast. What action is the nurse's priority?
Correct Answer: Monitor the client for hypoglycemia
Explanation: Administering too much insulin can lead to hypoglycemia, which is a
medical emergency.
A nurse is planning care for a pt who has a new diagnosis of DI. Which of the following
interventions should the nurse include in the plan of care?
Correct Answer: Check urine specific gravity
Explanation: In DI, urine specific gravity is low due to the inability to concentrate urine.
A nurse is caring for a pt admitted with wheezing and coughing due to an allergic reaction
to a newly prescribed medication. What medication should be administered first?
Correct Answer: Albuterol 3 mL via nebulizer
Explanation: Albuterol is a bronchodilator that relieves wheezing and bronchospasm
caused by an allergic reaction.
, A nurse is caring for a female client in the ED who reports SOB and pain in the lung area.
She states that she started taking BC pills 3 weeks ago and that she smokes. Her heart rate
is 110/min, RR 40/min, and BP 140/80. Her ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3
20, SaO2 86%. What is the priority of nursing interventions?
Correct Answer: Administer oxygen via face mask
Explanation: The ABG results indicate respiratory alkalosis and hypoxemia, likely due
to a pulmonary embolism (PE). Oxygen is the priority to improve oxygenation.
A nurse is caring for a pt following repair of a fracture. What finding should alert the
nurse that the pt is experiencing compartment syndrome?
Correct Answer: Unrelieved pain, pallor, pulselessness, numbness, pins and needles
sensation, swelling, tightness of the affected extremity
Explanation: These are the classic signs of compartment syndrome, a medical
emergency requiring immediate intervention.
A nurse is administering a tap water enema to a pt who is constipated. During the
administration of the enema, the client states he is having abdominal cramps. What action
should the nurse take to relieve the client's comfort?
Correct Answer: Lower the height of the solution container
Explanation: Lowering the height of the container slows the flow of the enema, reducing
cramping.
A pt is diagnosed with left homonymous hemianopsia following a stroke. What action
should the nurse take?
Correct Answer: Place the client's bedside table on the right side of the bed
Explanation: Left homonymous hemianopsia causes loss of vision in the left visual field.
Placing items on the right side ensures the client can see them.
A nurse is caring for a pt who is at risk for shock. What finding is the earliest indicator that
this complication is developing?
Correct Answer: Narrowing pulse pressure
Explanation: Narrowing pulse pressure (difference between systolic and diastolic BP) is
an early sign of shock due to decreased cardiac output.
