Med-Surg ATI Capstone – 2025/2026 Updated
Study Guide & Practice Questions | NCLEX
Exam Prep | 100% Pass Guarantee
A nurse on a med surg unit is caring for a group of clients. The nurse should notify the
rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse - correct
answerB
A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids - correct answerB, C, E
A nurse in the emergency department is caring for a client who fell through the ice on a
pond and is unresponsive and breathing slowly. Which of the following actions should
the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - correct answerA, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner states,
"He was pulling weeds in the yard and slumped to the ground." Which of the following
techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - correct answerA
, A nurse is reviewing the common emergency management protocol for clients who
have asystole. Which of the following actions should the nurse plan to take during this
cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities - correct answerC
A nurse is caring for a client who is postprocedural following LP and reports throbbing
headache when sitting upright. Which of the following actions should the nurse take?
(Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises -
correct answerB, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor
the client for which of the following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - correct answerB
A nurse is assessing a client for changes in the level of consciousness using the GCS.
The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - correct answerB
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client should
the nurse report to the provider? (Select all that apply)
A. "I think I might be pregnant"
B. "I take warfarin"
Study Guide & Practice Questions | NCLEX
Exam Prep | 100% Pass Guarantee
A nurse on a med surg unit is caring for a group of clients. The nurse should notify the
rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse - correct
answerB
A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids - correct answerB, C, E
A nurse in the emergency department is caring for a client who fell through the ice on a
pond and is unresponsive and breathing slowly. Which of the following actions should
the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - correct answerA, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner states,
"He was pulling weeds in the yard and slumped to the ground." Which of the following
techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - correct answerA
, A nurse is reviewing the common emergency management protocol for clients who
have asystole. Which of the following actions should the nurse plan to take during this
cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities - correct answerC
A nurse is caring for a client who is postprocedural following LP and reports throbbing
headache when sitting upright. Which of the following actions should the nurse take?
(Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises -
correct answerB, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor
the client for which of the following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - correct answerB
A nurse is assessing a client for changes in the level of consciousness using the GCS.
The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - correct answerB
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client should
the nurse report to the provider? (Select all that apply)
A. "I think I might be pregnant"
B. "I take warfarin"
