ATI CAPSTONE ADULT MEDICAL
SURGICAL ASSESSMENT 2 100 EXPERT
PRACTICE QUESTIONS AND DETAILED
RATIONALES COMPREHENSIVE 2026
BLUEPRINT
Domain 1: Prioritization, Delegation, and Clinical
Judgment
Question 1
A charge nurse is reviewing the client assignments on a medical-
surgical unit. Which of the following tasks should the nurse
delegate to an advanced unlicensed assistive personnel (UAP)?
A. Post-operative vital signs on a client who returned from a total
knee arthroplasty 1 hour ago.
B. Intermittent straight catheterization for a client with a history
of neurogenic bladder.
C. Double-checking an initial subcutaneous dose of insulin
glargine with the primary nurse.
D. Performing a sterile dressing change on a stage 3 pressure
injury.
CORRECT ANSWER: B
RATiONAlE: Advanced or specially trained UAPs can
perform clean-technique intermittent straight urinary
catheterization in stable clients under state nurse practice acts.
Option A requires an RN because the client is within the critical
4-hour immediate post-operative window. Option C requires a
,licensed nurse for a high-alert medication double-check. Option
D requires sterile technique and assessment skills reserved for
licensed nursing staff.
Question 2
A nurse is caring for four clients on a telemetry unit. Which of the
following clients should the nurse assess first?
A. A client with atrial fibrillation whose heart rate increased from
82 to 114/min over the past hour.
B. A client with chronic heart failure who has 3+ pitting pedal
edema and a 1.4 kg (3 lb) weight gain in 24 hours.
C. A client 2 days post-myocardial infarction who reports sudden,
sharp chest pain that worsens with deep inspiration.
D. A client with an implantable cardioverter-defibrillator (ICD)
who reports receiving a shock 15 minutes ago and feels dizzy.
CORRECT ANSWER: D
RATiONAlE: A client who received an ICD shock and
experiences dizziness requires immediate evaluation to verify
device function, rhythm stability, and cardiac output. Option A
represents new-onset rapid ventricular response but is
secondary to potential device failure or unstable
tachyarrhythmia. Option B indicates chronic fluid volume
overload. Option C describes pericarditis, a common and
expected inflammatory finding post-MI that worsens with deep
breathing.
Domain 2: Cardiovascular and Hematologic Systems
Question 3
,A nurse is caring for a client who is 4 hours post-percutaneous
coronary intervention (PCI) via the right femoral artery access
site. Which of the following findings requires immediate nursing
intervention?
A. The client reports mild discomfort at the arterial puncture site,
rated 2 out of 10.
B. The right dorsalis pedis pulse is 1+ palpable, while the left
dorsalis pedis pulse is 2+.
C. A firm, nickel-sized area of ecchymosis is noted directly
surrounding the insertion site.
D. The client's heart rate drops from 74/min to 52/min,
accompanied by a blood pressure of 88/54 mm Hg.
CORRECT ANSWER: D
RATiONAlE: Sudden bradycardia and hypotension post-
femoral PCI indicate a vasovagal reaction or retroperitoneal
hemorrhage. This demands rapid IV fluid resuscitation and
atropine. Option A and C are minor, expected post-procedure
findings. Option B shows minor asymmetry but is less critical
than systemic hemodynamic collapse.
Question 4
A nurse is assessing a client with a deep vein thrombosis (DVT)
who has been receiving a continuous intravenous heparin infusion
for the past 3 days. The client's platelet count has decreased from
210,000/mm³ to 95,000/mm³. Which of the following actions
should the nurse take first?
A. Stop the heparin infusion immediately.
B. Prepare to administer protamine sulfate.
, C. Obtain a stool sample for occult blood testing.
D. Request a prescription for an oral vitamin K antagonist.
CORRECT ANSWER: A
RATiONAlE: A drop in platelet count greater than 50% from
baseline during heparin therapy strongly indicates Heparin-
Induced Thrombocytopenia (HIT). The immediate priority is to
stop all heparin products to stop thrombotic complications.
Protamine sulfate is for heparin reversal in active hemorrhage.
Stool testing is useful but non-urgent. Vitamin K antagonists are
contraindicated during acute HIT.
Domain 3: Respiratory and Ventilation Systems
Question 5
A nurse is caring for a client on mechanical ventilation in the
intensive care unit. The low-pressure alarm on the ventilator
begins sounding. Which of the following actions should the nurse
perform first?
A. Suction the client’s endotracheal tube to remove thick
secretions.
B. Check the ventilator tubing connections for an accidental
disconnection.
C. Increase the oxygen concentration setting on the ventilator to
100%.
D. Manually ventilate the client using a bag-valve-mask device.
CORRECT ANSWER: B
RATiONAlE: Low-pressure alarms are most commonly
SURGICAL ASSESSMENT 2 100 EXPERT
PRACTICE QUESTIONS AND DETAILED
RATIONALES COMPREHENSIVE 2026
BLUEPRINT
Domain 1: Prioritization, Delegation, and Clinical
Judgment
Question 1
A charge nurse is reviewing the client assignments on a medical-
surgical unit. Which of the following tasks should the nurse
delegate to an advanced unlicensed assistive personnel (UAP)?
A. Post-operative vital signs on a client who returned from a total
knee arthroplasty 1 hour ago.
B. Intermittent straight catheterization for a client with a history
of neurogenic bladder.
C. Double-checking an initial subcutaneous dose of insulin
glargine with the primary nurse.
D. Performing a sterile dressing change on a stage 3 pressure
injury.
CORRECT ANSWER: B
RATiONAlE: Advanced or specially trained UAPs can
perform clean-technique intermittent straight urinary
catheterization in stable clients under state nurse practice acts.
Option A requires an RN because the client is within the critical
4-hour immediate post-operative window. Option C requires a
,licensed nurse for a high-alert medication double-check. Option
D requires sterile technique and assessment skills reserved for
licensed nursing staff.
Question 2
A nurse is caring for four clients on a telemetry unit. Which of the
following clients should the nurse assess first?
A. A client with atrial fibrillation whose heart rate increased from
82 to 114/min over the past hour.
B. A client with chronic heart failure who has 3+ pitting pedal
edema and a 1.4 kg (3 lb) weight gain in 24 hours.
C. A client 2 days post-myocardial infarction who reports sudden,
sharp chest pain that worsens with deep inspiration.
D. A client with an implantable cardioverter-defibrillator (ICD)
who reports receiving a shock 15 minutes ago and feels dizzy.
CORRECT ANSWER: D
RATiONAlE: A client who received an ICD shock and
experiences dizziness requires immediate evaluation to verify
device function, rhythm stability, and cardiac output. Option A
represents new-onset rapid ventricular response but is
secondary to potential device failure or unstable
tachyarrhythmia. Option B indicates chronic fluid volume
overload. Option C describes pericarditis, a common and
expected inflammatory finding post-MI that worsens with deep
breathing.
Domain 2: Cardiovascular and Hematologic Systems
Question 3
,A nurse is caring for a client who is 4 hours post-percutaneous
coronary intervention (PCI) via the right femoral artery access
site. Which of the following findings requires immediate nursing
intervention?
A. The client reports mild discomfort at the arterial puncture site,
rated 2 out of 10.
B. The right dorsalis pedis pulse is 1+ palpable, while the left
dorsalis pedis pulse is 2+.
C. A firm, nickel-sized area of ecchymosis is noted directly
surrounding the insertion site.
D. The client's heart rate drops from 74/min to 52/min,
accompanied by a blood pressure of 88/54 mm Hg.
CORRECT ANSWER: D
RATiONAlE: Sudden bradycardia and hypotension post-
femoral PCI indicate a vasovagal reaction or retroperitoneal
hemorrhage. This demands rapid IV fluid resuscitation and
atropine. Option A and C are minor, expected post-procedure
findings. Option B shows minor asymmetry but is less critical
than systemic hemodynamic collapse.
Question 4
A nurse is assessing a client with a deep vein thrombosis (DVT)
who has been receiving a continuous intravenous heparin infusion
for the past 3 days. The client's platelet count has decreased from
210,000/mm³ to 95,000/mm³. Which of the following actions
should the nurse take first?
A. Stop the heparin infusion immediately.
B. Prepare to administer protamine sulfate.
, C. Obtain a stool sample for occult blood testing.
D. Request a prescription for an oral vitamin K antagonist.
CORRECT ANSWER: A
RATiONAlE: A drop in platelet count greater than 50% from
baseline during heparin therapy strongly indicates Heparin-
Induced Thrombocytopenia (HIT). The immediate priority is to
stop all heparin products to stop thrombotic complications.
Protamine sulfate is for heparin reversal in active hemorrhage.
Stool testing is useful but non-urgent. Vitamin K antagonists are
contraindicated during acute HIT.
Domain 3: Respiratory and Ventilation Systems
Question 5
A nurse is caring for a client on mechanical ventilation in the
intensive care unit. The low-pressure alarm on the ventilator
begins sounding. Which of the following actions should the nurse
perform first?
A. Suction the client’s endotracheal tube to remove thick
secretions.
B. Check the ventilator tubing connections for an accidental
disconnection.
C. Increase the oxygen concentration setting on the ventilator to
100%.
D. Manually ventilate the client using a bag-valve-mask device.
CORRECT ANSWER: B
RATiONAlE: Low-pressure alarms are most commonly
