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CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 QUESTIONS
AND ANSWERS
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"
Thoroughly shake the inhaler to disperse the medication
because the medication in the inhaler can separate easily
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
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Use electronic tablet computer, programmable speech
generating device, alphabet board, pencil and paper, etc
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
Within the expected range of 1.005-1.030
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
D. RBC 4.0 million - correct answer- C Platelets 80,000
platelet range is 150,000-400,000
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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
The greatest risk to a client who has a cervical spinal cord
injury is an obstructed airway; the priority is to ensure the client
can clear their airway. Apply abdominal pressure as the client
coughs (quad coughing)
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. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - correct answer- C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses,
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and confusion. Dyspnea can also indicate transfusion related
acute lung injury to an anaphylactic response, which also
causes wheezing, chest tightness, cyanosis, and low BP
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
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
Altered taste is a result of the release of metabolites by dead
cells
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
CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 QUESTIONS
AND ANSWERS
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"
Thoroughly shake the inhaler to disperse the medication
because the medication in the inhaler can separate easily
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
,2 | Page
Use electronic tablet computer, programmable speech
generating device, alphabet board, pencil and paper, etc
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
Within the expected range of 1.005-1.030
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
D. RBC 4.0 million - correct answer- C Platelets 80,000
platelet range is 150,000-400,000
,3 | Page
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
The greatest risk to a client who has a cervical spinal cord
injury is an obstructed airway; the priority is to ensure the client
can clear their airway. Apply abdominal pressure as the client
coughs (quad coughing)
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. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - correct answer- C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses,
, 4 | Page
and confusion. Dyspnea can also indicate transfusion related
acute lung injury to an anaphylactic response, which also
causes wheezing, chest tightness, cyanosis, and low BP
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
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
Altered taste is a result of the release of metabolites by dead
cells
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
