ATI Capstone Adult Medical Surgical Assessment 1,
Actual Exam Questions & Answers (Deeply Explained
Answers) guaranteed a+
1. A patient is being treated for hypertension with a diuretic.
Which of the following assessments is most important for
the nurse to monitor?
A) Blood glucose levels
B) Serum potassium levels
C) Heart rate
D) Respiratory rate
Answer: B) Serum potassium levels
Rationale: Diuretics, esp
2. A nurse is caring for a client with heart failure. Which of
the following findings would indicate worsening heart
failure?
A) Decreased heart rate
B) Weight loss
C) Increased peripheral edema
D) Improved exercise tolerance
Answer: C) Increased peripheral edema
Rationale: Increased peripheral edema suggests fluid retention
and worsening heart failure, requiring further evaluation and
possible intervention.
,1|Page
3. A patient is receiving morphine for pain management.
Which of the following should the nurse monitor closely?
A) Blood pressure
B) Respiratory rate
C) Urine output
D) Heart rate
Answer: B) Respiratory rate
Rationale: Morphine can cause respiratory depression, so
monitoring the patient's respiratory rate is crucial to ensure safety.
4. A patient is scheduled for a total hip replacement. What is
the most important postoperative intervention the nurse
should implement?
A) Assess pain levels
B) Encourage deep breathing and coughing
C) Monitor for signs of infection
D) Ensure proper positioning of the affected leg
Answer: D) Ensure proper positioning of the affected leg
Rationale: Proper positioning is vital to prevent dislocation of the
hip and promote optimal healing after surgery.
5. A nurse is caring for a patient with diabetes who has a
blood glucose level of 350 mg/dL. Which of the following
actions should the nurse take first?
A) Administer insulin as prescribed
B) Encourage the patient to drink water
C) Recheck the blood glucose in one hour
D) Document the findings
,2|Page
Answer: A) Administer insulin as prescribed
Rationale: High blood glucose levels require immediate
intervention to prevent complications such as diabetic
ketoacidosis.
6. A patient presents with acute chest pain and shortness of
breath. What is the priority nursing action?
A) Obtain a history of the present illness
B) Administer oxygen therapy
C) Call for a physician
D) Perform a 12-lead ECG
Answer: B) Administer oxygen therapy
Rationale: Ensuring adequate oxygenation is the priority in a
patient with chest pain and respiratory distress.
7. A nurse is educating a patient about a low-sodium diet.
Which of the following foods should the nurse recommend?
A) Canned soup
B) Fresh fruits
C) Processed cheese
D) Salty snacks
Answer: B) Fresh fruits
Rationale: Fresh fruits are naturally low in sodium and are a
healthier option for a low-sodium diet.
, 3|Page
8. A patient undergoing chemotherapy is at risk for
neutropenia. Which of the following assessments is a
priority?
A) Assess for fever
B) Monitor for weight loss
C) Check for nausea
D) Evaluate for fatigue
Answer: A) Assess for fever
Rationale: Fever may indicate an infection, which can be serious
in patients with neutropenia due to their compromised immune
system.
9. A patient with chronic obstructive pulmonary disease
(COPD) is experiencing increased dyspnea. Which of the
following interventions should the nurse implement first?
A) Administer bronchodilator therapy
B) Position the patient in high Fowler’s
C) Encourage pursed-lip breathing
D) Assess lung sounds
Answer: B) Position the patient in high Fowler’s
Rationale: Positioning the patient in high Fowler’s can help
facilitate easier breathing and improve ventilation.
10. The nurse is caring for a patient with a suspected stroke.
Which of the following assessments is most critical for the
nurse to perform immediately?
A) Glasgow Coma Scale
B) Motor function assessment
Actual Exam Questions & Answers (Deeply Explained
Answers) guaranteed a+
1. A patient is being treated for hypertension with a diuretic.
Which of the following assessments is most important for
the nurse to monitor?
A) Blood glucose levels
B) Serum potassium levels
C) Heart rate
D) Respiratory rate
Answer: B) Serum potassium levels
Rationale: Diuretics, esp
2. A nurse is caring for a client with heart failure. Which of
the following findings would indicate worsening heart
failure?
A) Decreased heart rate
B) Weight loss
C) Increased peripheral edema
D) Improved exercise tolerance
Answer: C) Increased peripheral edema
Rationale: Increased peripheral edema suggests fluid retention
and worsening heart failure, requiring further evaluation and
possible intervention.
,1|Page
3. A patient is receiving morphine for pain management.
Which of the following should the nurse monitor closely?
A) Blood pressure
B) Respiratory rate
C) Urine output
D) Heart rate
Answer: B) Respiratory rate
Rationale: Morphine can cause respiratory depression, so
monitoring the patient's respiratory rate is crucial to ensure safety.
4. A patient is scheduled for a total hip replacement. What is
the most important postoperative intervention the nurse
should implement?
A) Assess pain levels
B) Encourage deep breathing and coughing
C) Monitor for signs of infection
D) Ensure proper positioning of the affected leg
Answer: D) Ensure proper positioning of the affected leg
Rationale: Proper positioning is vital to prevent dislocation of the
hip and promote optimal healing after surgery.
5. A nurse is caring for a patient with diabetes who has a
blood glucose level of 350 mg/dL. Which of the following
actions should the nurse take first?
A) Administer insulin as prescribed
B) Encourage the patient to drink water
C) Recheck the blood glucose in one hour
D) Document the findings
,2|Page
Answer: A) Administer insulin as prescribed
Rationale: High blood glucose levels require immediate
intervention to prevent complications such as diabetic
ketoacidosis.
6. A patient presents with acute chest pain and shortness of
breath. What is the priority nursing action?
A) Obtain a history of the present illness
B) Administer oxygen therapy
C) Call for a physician
D) Perform a 12-lead ECG
Answer: B) Administer oxygen therapy
Rationale: Ensuring adequate oxygenation is the priority in a
patient with chest pain and respiratory distress.
7. A nurse is educating a patient about a low-sodium diet.
Which of the following foods should the nurse recommend?
A) Canned soup
B) Fresh fruits
C) Processed cheese
D) Salty snacks
Answer: B) Fresh fruits
Rationale: Fresh fruits are naturally low in sodium and are a
healthier option for a low-sodium diet.
, 3|Page
8. A patient undergoing chemotherapy is at risk for
neutropenia. Which of the following assessments is a
priority?
A) Assess for fever
B) Monitor for weight loss
C) Check for nausea
D) Evaluate for fatigue
Answer: A) Assess for fever
Rationale: Fever may indicate an infection, which can be serious
in patients with neutropenia due to their compromised immune
system.
9. A patient with chronic obstructive pulmonary disease
(COPD) is experiencing increased dyspnea. Which of the
following interventions should the nurse implement first?
A) Administer bronchodilator therapy
B) Position the patient in high Fowler’s
C) Encourage pursed-lip breathing
D) Assess lung sounds
Answer: B) Position the patient in high Fowler’s
Rationale: Positioning the patient in high Fowler’s can help
facilitate easier breathing and improve ventilation.
10. The nurse is caring for a patient with a suspected stroke.
Which of the following assessments is most critical for the
nurse to perform immediately?
A) Glasgow Coma Scale
B) Motor function assessment
