ESTUDYR
Capstone ATI NCLEX Medical Surgical Assessment 1, ATI
Capstone Adult Medical Surgical Assessment 2
100% GUARANTEE PASS
Question 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.”
Correct Answer: D) “Shake the inhaler vigorously prior to use.”
Rationale: The medication in the inhaler can separate easily, so it is crucial to thoroughly shake
the inhaler to ensure the medication is evenly dispersed before administration. This ensures the
client receives the correct dose and therapeutic effect.
Question 2
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.
Correct Answer: A) Provide the client with a means of communication.
Rationale: Clients on mechanical ventilation are often unable to speak due to the endotracheal
tube. Providing a means of communication (e.g., electronic tablet, alphabet board, pen and
paper) is essential to reduce anxiety, allow expression of needs, and facilitate patient-centered
care. Maintaining the head of the bed elevated (typically 30-45 degrees) is important to prevent
ventilator-associated pneumonia, and oral hygiene should be performed more frequently (e.g.,
every 2-4 hours) to prevent infections.
,ESTUDYR
Question 3
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%
Correct Answer: C) Urine specific gravity 1.020.
Rationale: Urine specific gravity measures the concentration of solutes in the urine and is a
good indicator of hydration status. A normal range is typically 1.005-1.030. A value of 1.020
indicates that the kidneys are concentrating urine appropriately, suggesting improved
hydration. Sodium 165 mEq/L and Hct 62% would indicate persistent dehydration (normal
sodium 135-145 mEq/L, normal Hct 37-52%), while potassium 5.2 mEq/L is slightly elevated but
not a primary indicator of hydration status (normal potassium 3.5-5.0 mEq/L).
Question 4
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/mm³
D. RBC 4.0 million/µL
Correct Answer: C) Platelets 80,000/mm³.
Rationale: The normal platelet count range is 150,000-400,000/mm³. A platelet count of
80,000/mm³ is significantly below the normal range, indicating thrombocytopenia, which
increases the client’s risk for bleeding. PT (normal 11-13.5 seconds) and aPTT (normal 25-35
seconds) are within or near normal limits, and RBC count (normal 4.2-5.4 million/µL for
females, 4.7-6.1 million/µL for males) is slightly low but not the primary indicator of increased
bleeding risk in this context.
,ESTUDYR
Question 5
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.
Correct Answer: D) Assist the client with quad coughing.
Rationale: According to the airway, breathing, circulation (ABC) priority framework, maintaining
a patent airway is paramount. For a client with a cervical spinal cord injury, the greatest risk is
an obstructed airway due to impaired respiratory muscle function. Quad coughing (applying
abdominal pressure during a cough) helps the client clear secretions and maintain airway
patency, making it the priority intervention. While other options are important for client care,
they are not immediately life-saving.
Question 6
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. Nausea
B. Hypothermia
C. Dyspnea
D. Bradycardia
Correct Answer: C) Dyspnea.
Rationale: Dyspnea (shortness of breath) is a key indicator of transfusion-associated circulatory
overload (TACO), which occurs when the rate or volume of blood transfusion exceeds the
client’s circulatory system capacity. Other signs include hypertension, bounding pulses, and
confusion. Dyspnea can also be a sign of other transfusion reactions like transfusion-related
acute lung injury (TRALI) or anaphylaxis, both of which require immediate intervention.
Question 7
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?
, ESTUDYR
A. Hair loss on the scalp.
B. Sweating at the treatment site.
C. Altered taste sensations.
D. Intolerance to cold.
Correct Answer: C) Altered taste sensations.
Rationale: Radiation therapy, especially to the head and neck or chest, can cause altered taste
sensations (dysgeusia) due to damage to taste buds and salivary glands. This is a common and
often distressing side effect that can impact nutritional intake. Hair loss on the scalp is typically
associated with radiation to the head, not necessarily the chest. Sweating at the treatment site
and intolerance to cold are not typical adverse effects of chest radiation.
Question 8
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.
Correct Answer: A, D, E.
Rationale: * A) Obtain pre-transfusion temperature: A complete assessment, including vital
signs, is crucial before starting a transfusion to establish a baseline and identify any pre-existing
conditions that might contraindicate the transfusion or mask a reaction. * D) Verify the client’s
blood type with a second nurse: Two-person verification of client identification, blood
compatibility, and product expiration is a critical safety measure to prevent transfusion errors
and ensure the correct blood product is given to the correct client. * E) Use a 20 gauge IV
needle for venous access: A large-bore IV needle (e.g., 18 or 20 gauge) is recommended for
blood transfusions to reduce the risk of red blood cell hemolysis (destruction) and obstruction
of blood flow, ensuring efficient and safe delivery of the product.
Incorrect Rationales: * B) Prime the IV tubing with lactated Ringer’s: IV tubing for blood
transfusions should be primed with 0.9% sodium chloride (normal saline) only. Lactated
Ringer’s contains calcium, which can cause clotting in the blood product. * C) Instruct an
assistive personnel to monitor the client during the transfusion: While assistive personnel can
assist with some aspects of care, the nurse is responsible for direct monitoring of the client
Capstone ATI NCLEX Medical Surgical Assessment 1, ATI
Capstone Adult Medical Surgical Assessment 2
100% GUARANTEE PASS
Question 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.”
Correct Answer: D) “Shake the inhaler vigorously prior to use.”
Rationale: The medication in the inhaler can separate easily, so it is crucial to thoroughly shake
the inhaler to ensure the medication is evenly dispersed before administration. This ensures the
client receives the correct dose and therapeutic effect.
Question 2
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.
Correct Answer: A) Provide the client with a means of communication.
Rationale: Clients on mechanical ventilation are often unable to speak due to the endotracheal
tube. Providing a means of communication (e.g., electronic tablet, alphabet board, pen and
paper) is essential to reduce anxiety, allow expression of needs, and facilitate patient-centered
care. Maintaining the head of the bed elevated (typically 30-45 degrees) is important to prevent
ventilator-associated pneumonia, and oral hygiene should be performed more frequently (e.g.,
every 2-4 hours) to prevent infections.
,ESTUDYR
Question 3
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%
Correct Answer: C) Urine specific gravity 1.020.
Rationale: Urine specific gravity measures the concentration of solutes in the urine and is a
good indicator of hydration status. A normal range is typically 1.005-1.030. A value of 1.020
indicates that the kidneys are concentrating urine appropriately, suggesting improved
hydration. Sodium 165 mEq/L and Hct 62% would indicate persistent dehydration (normal
sodium 135-145 mEq/L, normal Hct 37-52%), while potassium 5.2 mEq/L is slightly elevated but
not a primary indicator of hydration status (normal potassium 3.5-5.0 mEq/L).
Question 4
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/mm³
D. RBC 4.0 million/µL
Correct Answer: C) Platelets 80,000/mm³.
Rationale: The normal platelet count range is 150,000-400,000/mm³. A platelet count of
80,000/mm³ is significantly below the normal range, indicating thrombocytopenia, which
increases the client’s risk for bleeding. PT (normal 11-13.5 seconds) and aPTT (normal 25-35
seconds) are within or near normal limits, and RBC count (normal 4.2-5.4 million/µL for
females, 4.7-6.1 million/µL for males) is slightly low but not the primary indicator of increased
bleeding risk in this context.
,ESTUDYR
Question 5
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.
Correct Answer: D) Assist the client with quad coughing.
Rationale: According to the airway, breathing, circulation (ABC) priority framework, maintaining
a patent airway is paramount. For a client with a cervical spinal cord injury, the greatest risk is
an obstructed airway due to impaired respiratory muscle function. Quad coughing (applying
abdominal pressure during a cough) helps the client clear secretions and maintain airway
patency, making it the priority intervention. While other options are important for client care,
they are not immediately life-saving.
Question 6
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. Nausea
B. Hypothermia
C. Dyspnea
D. Bradycardia
Correct Answer: C) Dyspnea.
Rationale: Dyspnea (shortness of breath) is a key indicator of transfusion-associated circulatory
overload (TACO), which occurs when the rate or volume of blood transfusion exceeds the
client’s circulatory system capacity. Other signs include hypertension, bounding pulses, and
confusion. Dyspnea can also be a sign of other transfusion reactions like transfusion-related
acute lung injury (TRALI) or anaphylaxis, both of which require immediate intervention.
Question 7
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?
, ESTUDYR
A. Hair loss on the scalp.
B. Sweating at the treatment site.
C. Altered taste sensations.
D. Intolerance to cold.
Correct Answer: C) Altered taste sensations.
Rationale: Radiation therapy, especially to the head and neck or chest, can cause altered taste
sensations (dysgeusia) due to damage to taste buds and salivary glands. This is a common and
often distressing side effect that can impact nutritional intake. Hair loss on the scalp is typically
associated with radiation to the head, not necessarily the chest. Sweating at the treatment site
and intolerance to cold are not typical adverse effects of chest radiation.
Question 8
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.
Correct Answer: A, D, E.
Rationale: * A) Obtain pre-transfusion temperature: A complete assessment, including vital
signs, is crucial before starting a transfusion to establish a baseline and identify any pre-existing
conditions that might contraindicate the transfusion or mask a reaction. * D) Verify the client’s
blood type with a second nurse: Two-person verification of client identification, blood
compatibility, and product expiration is a critical safety measure to prevent transfusion errors
and ensure the correct blood product is given to the correct client. * E) Use a 20 gauge IV
needle for venous access: A large-bore IV needle (e.g., 18 or 20 gauge) is recommended for
blood transfusions to reduce the risk of red blood cell hemolysis (destruction) and obstruction
of blood flow, ensuring efficient and safe delivery of the product.
Incorrect Rationales: * B) Prime the IV tubing with lactated Ringer’s: IV tubing for blood
transfusions should be primed with 0.9% sodium chloride (normal saline) only. Lactated
Ringer’s contains calcium, which can cause clotting in the blood product. * C) Instruct an
assistive personnel to monitor the client during the transfusion: While assistive personnel can
assist with some aspects of care, the nurse is responsible for direct monitoring of the client
