ATI CAPSTONE NCLEX MEDICAL SURGICAL ASSESSMENT 1
EXAM WITH ACTUAL 70 QUESTION AND CORRECT DETAILED
ANSWERS WITH RATIONALES.
A nurse in an endoscopy clinic is providing preoperative teaching to a client who is
scheduled to undergo a colonoscopy for colorectal cancer screening. Which of the
following instructions should the nurse include in the teaching session?
A) "You should have nothing to eat or drink for 3 hours prior to the procedure."
B) "You should drink the bowel preparation solution slowly to prevent nausea."
C) "You will have no discomfort following the procedure."
D) "You will need someone to drive you home after your procedure."
Correct Answer: D
Rationale
Colonoscopy is an invasive diagnostic procedure that requires the administration of
moderate sedation, typically with medications such as midazolam and fentanyl, to
promote client comfort and cooperation. The sedative effects can persist for 12 to
18 hours following the procedure, impairing cognitive function, judgment, and
motor coordination. Therefore, it is imperative that the client arrange for a
responsible adult to provide transportation home and remain with them for a
period after discharge to ensure safety. Option A is incorrect because the standard
fasting period for colonoscopy is typically 6 to 8 hours, not 3 hours, to ensure
adequate bowel cleansing and reduce the risk of aspiration. Option B is incorrect
because the bowel preparation solution should be consumed as directed, often in
divided doses, but drinking it slowly may not achieve the necessary cleansing
effect; instead, clients are often advised to drink it at a steady pace to complete
the regimen within the specified timeframe. Option C is incorrect because clients
may experience cramping, bloating, or mild discomfort due to air insufflation
during the procedure, and it is unrealistic to promise no discomfort. Therefore, the
most critical instruction is arranging for a driver.
A nurse is monitoring a client who is receiving moderate sedation with midazolam
during a diagnostic procedure. Which of the following assessment 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
Rationale
Moderate sedation, formerly termed conscious sedation, is a pharmacologically
induced state in which the client maintains a patent airway, protective reflexes,
and the ability to respond purposefully to verbal commands or light tactile
stimulation. The client's failure to respond to verbal stimuli indicates a progression
from moderate sedation to deep sedation or general anesthesia, which places the
client at significant risk for respiratory depression, airway obstruction, and
aspiration. This finding demands immediate intervention, including assessment of
the client's level of consciousness, airway patency, and vital signs, and may
necessitate the administration of the reversal agent flumazenil or other
resuscitative measures. Option A, an oxygen saturation of 90%, is concerning and
requires intervention, but it is a secondary consequence of the more immediate
issue of oversedation; however, the loss of response to verbal stimuli is the more
urgent priority. Option C, occasional premature ventricular contractions, may be
benign in a monitored setting but is not as immediately life-threatening as the loss
of consciousness. Option D, nausea, is a common side effect that can be managed
but does not require immediate intervention. Therefore, the client's
unresponsiveness to verbal stimuli is the highest priority.
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
Rationale
Furosemide is a potent loop diuretic that acts on the ascending limb of the loop of
,Henle to inhibit sodium, chloride, and potassium reabsorption. This mechanism
results in significant diuresis and electrolyte losses, particularly potassium, leading
to hypokalemia. A serum potassium level of 3.2 mEq/L is below the expected
reference range of 3.5 to 5.0 mEq/L and indicates hypokalemia, a serious adverse
effect that can predispose the client to cardiac dysrhythmias, especially if the client
is also receiving digitalis preparations. Option A, sodium 142 mEq/L, is within the
normal range of 135 to 145 mEq/L and does not indicate an adverse effect. Option
B, metabolic acidosis, is not typically associated with furosemide; rather, metabolic
alkalosis can occur due to volume contraction and loss of hydrogen ions. Option D,
hypoglycemia, is not a recognized adverse effect of furosemide; hyperglycemia
may occur due to impaired glucose tolerance. Therefore, the hypokalemia is the
critical finding requiring intervention.
A nurse is teaching a client how to administer a medication using a metered-dose
inhaler with a spacer device. Which of the following instructions should the nurse
include in the teaching?
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
Rationale
Proper technique for using a metered-dose inhaler (MDI) is essential for ensuring
adequate medication delivery to the lungs. The medication in an MDI is suspended
in a propellant and can separate or settle over time. Vigorous shaking of the
inhaler prior to each use is crucial to disperse the medication particles evenly,
ensuring consistent dosing with each actuation. Option A is incorrect because the
recommended waiting time between puffs is typically 1 to 2 minutes, not 5
minutes, to allow for optimal medication deposition. Option B is incorrect because
the client should breathe in slowly and deeply (not rapidly) over 3 to 5 seconds to
allow the medication to reach the lower airways; rapid inhalation can cause the
medication to impact the oropharynx. Option C is incorrect because the inhaler
cap and spacer should be cleaned weekly with warm water and allowed to air dry,
, not cold water, and the plastic cap may not require weekly cleaning. Therefore,
shaking the inhaler vigorously is the correct and critical instruction.
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 hours.
D) Perform oral hygiene for the client every 8 hours.
Correct Answer: A
Rationale
Clients receiving mechanical ventilation are often unable to speak due to the
presence of an endotracheal or tracheostomy tube, which passes through the
vocal cords. This inability to communicate can lead to significant anxiety,
frustration, and feelings of isolation. Providing alternative means of
communication, such as an electronic tablet, a programmable speech-generating
device, an alphabet board, or a communication board with pictures and words, is
essential to promote psychological well-being, reduce anxiety, and enable the
client to express needs and concerns. Option B is incorrect because the head of the
bed should be elevated to 30 to 45 degrees to reduce the risk of ventilator-
associated pneumonia and aspiration. Option C is incorrect because suctioning
should be performed on an as-needed basis, not on a fixed schedule, to prevent
mucosal trauma and hypoxia; indications include visible secretions, decreased
oxygen saturation, or increased peak inspiratory pressures. Option D is incorrect
because oral hygiene should be performed more frequently, at least every 2 to 4
hours, to reduce the risk of ventilator-associated pneumonia by preventing the
colonization of oral pathogens. Therefore, providing a communication method is
the most appropriate intervention.
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
EXAM WITH ACTUAL 70 QUESTION AND CORRECT DETAILED
ANSWERS WITH RATIONALES.
A nurse in an endoscopy clinic is providing preoperative teaching to a client who is
scheduled to undergo a colonoscopy for colorectal cancer screening. Which of the
following instructions should the nurse include in the teaching session?
A) "You should have nothing to eat or drink for 3 hours prior to the procedure."
B) "You should drink the bowel preparation solution slowly to prevent nausea."
C) "You will have no discomfort following the procedure."
D) "You will need someone to drive you home after your procedure."
Correct Answer: D
Rationale
Colonoscopy is an invasive diagnostic procedure that requires the administration of
moderate sedation, typically with medications such as midazolam and fentanyl, to
promote client comfort and cooperation. The sedative effects can persist for 12 to
18 hours following the procedure, impairing cognitive function, judgment, and
motor coordination. Therefore, it is imperative that the client arrange for a
responsible adult to provide transportation home and remain with them for a
period after discharge to ensure safety. Option A is incorrect because the standard
fasting period for colonoscopy is typically 6 to 8 hours, not 3 hours, to ensure
adequate bowel cleansing and reduce the risk of aspiration. Option B is incorrect
because the bowel preparation solution should be consumed as directed, often in
divided doses, but drinking it slowly may not achieve the necessary cleansing
effect; instead, clients are often advised to drink it at a steady pace to complete
the regimen within the specified timeframe. Option C is incorrect because clients
may experience cramping, bloating, or mild discomfort due to air insufflation
during the procedure, and it is unrealistic to promise no discomfort. Therefore, the
most critical instruction is arranging for a driver.
A nurse is monitoring a client who is receiving moderate sedation with midazolam
during a diagnostic procedure. Which of the following assessment 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
Rationale
Moderate sedation, formerly termed conscious sedation, is a pharmacologically
induced state in which the client maintains a patent airway, protective reflexes,
and the ability to respond purposefully to verbal commands or light tactile
stimulation. The client's failure to respond to verbal stimuli indicates a progression
from moderate sedation to deep sedation or general anesthesia, which places the
client at significant risk for respiratory depression, airway obstruction, and
aspiration. This finding demands immediate intervention, including assessment of
the client's level of consciousness, airway patency, and vital signs, and may
necessitate the administration of the reversal agent flumazenil or other
resuscitative measures. Option A, an oxygen saturation of 90%, is concerning and
requires intervention, but it is a secondary consequence of the more immediate
issue of oversedation; however, the loss of response to verbal stimuli is the more
urgent priority. Option C, occasional premature ventricular contractions, may be
benign in a monitored setting but is not as immediately life-threatening as the loss
of consciousness. Option D, nausea, is a common side effect that can be managed
but does not require immediate intervention. Therefore, the client's
unresponsiveness to verbal stimuli is the highest priority.
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
Rationale
Furosemide is a potent loop diuretic that acts on the ascending limb of the loop of
,Henle to inhibit sodium, chloride, and potassium reabsorption. This mechanism
results in significant diuresis and electrolyte losses, particularly potassium, leading
to hypokalemia. A serum potassium level of 3.2 mEq/L is below the expected
reference range of 3.5 to 5.0 mEq/L and indicates hypokalemia, a serious adverse
effect that can predispose the client to cardiac dysrhythmias, especially if the client
is also receiving digitalis preparations. Option A, sodium 142 mEq/L, is within the
normal range of 135 to 145 mEq/L and does not indicate an adverse effect. Option
B, metabolic acidosis, is not typically associated with furosemide; rather, metabolic
alkalosis can occur due to volume contraction and loss of hydrogen ions. Option D,
hypoglycemia, is not a recognized adverse effect of furosemide; hyperglycemia
may occur due to impaired glucose tolerance. Therefore, the hypokalemia is the
critical finding requiring intervention.
A nurse is teaching a client how to administer a medication using a metered-dose
inhaler with a spacer device. Which of the following instructions should the nurse
include in the teaching?
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
Rationale
Proper technique for using a metered-dose inhaler (MDI) is essential for ensuring
adequate medication delivery to the lungs. The medication in an MDI is suspended
in a propellant and can separate or settle over time. Vigorous shaking of the
inhaler prior to each use is crucial to disperse the medication particles evenly,
ensuring consistent dosing with each actuation. Option A is incorrect because the
recommended waiting time between puffs is typically 1 to 2 minutes, not 5
minutes, to allow for optimal medication deposition. Option B is incorrect because
the client should breathe in slowly and deeply (not rapidly) over 3 to 5 seconds to
allow the medication to reach the lower airways; rapid inhalation can cause the
medication to impact the oropharynx. Option C is incorrect because the inhaler
cap and spacer should be cleaned weekly with warm water and allowed to air dry,
, not cold water, and the plastic cap may not require weekly cleaning. Therefore,
shaking the inhaler vigorously is the correct and critical instruction.
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 hours.
D) Perform oral hygiene for the client every 8 hours.
Correct Answer: A
Rationale
Clients receiving mechanical ventilation are often unable to speak due to the
presence of an endotracheal or tracheostomy tube, which passes through the
vocal cords. This inability to communicate can lead to significant anxiety,
frustration, and feelings of isolation. Providing alternative means of
communication, such as an electronic tablet, a programmable speech-generating
device, an alphabet board, or a communication board with pictures and words, is
essential to promote psychological well-being, reduce anxiety, and enable the
client to express needs and concerns. Option B is incorrect because the head of the
bed should be elevated to 30 to 45 degrees to reduce the risk of ventilator-
associated pneumonia and aspiration. Option C is incorrect because suctioning
should be performed on an as-needed basis, not on a fixed schedule, to prevent
mucosal trauma and hypoxia; indications include visible secretions, decreased
oxygen saturation, or increased peak inspiratory pressures. Option D is incorrect
because oral hygiene should be performed more frequently, at least every 2 to 4
hours, to reduce the risk of ventilator-associated pneumonia by preventing the
colonization of oral pathogens. Therefore, providing a communication method is
the most appropriate intervention.
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
