Capstone ATI NCLEX Medical Surgical
Assessment 1 with verified solutions
A nurse is teaching a client how to administer a medication using an inhaler
x x x x x x x x x x x x x x
with a spacer. Which of the following instructions should the nurse include
x x x x x x x x x x x
A. "Wait at least 5 minutes between puffs from the same inhaler"
x x x x x x x x x x x
B. "Breathe in rapidly when inhaling the medication"
x x x x x x x
C. "Clean the plastic inhaler cap weekly with cold water"
x x x x x x x x x
D. "Shake the inhaler vigorously prior to use" - correct answer ✔D .) "Shake
x x x x x x x x x x x x x x
the inhaler vigorously prior to use"
x x x x x
Thoroughly shake the inhaler to disperse the medication because the
x x x x x x x x x x
medication in the inhaler can separate easilyx x x x x x
A nurse is planning care for a client who is receiving mechanical ventilation.
x x x x x x x x x x x x x
Which of the following actions should the nurse include in the plan
x x x x x x x x x x x
A. Provide the client with a means of communication
x x x x x x x x
B. Maintain the head of the client's bed in a flat position
x x x x x x x x x x x
C. Suction the client's endotracheal tube every 4 hr
x x x x x x x x
D. Perform oral hygiene for the client every 8 hr - correct answer ✔A.)
x x x x x x x x x x x x x x
Provide the client with a means of communication
x x x x x x x
Use electronic tablet computer, programmable speech generating device,
x x x x x x x x
alphabet board, pencil and paper, etc
x x x x x
,A nurse is caring for a client who is receiving IV fluid replacement therapy for
x x x x x x x x x x x x x x
dehydration. Which of the following laboratory results indicates effectiveness
x x x x x x x x x
of the treatment
x x x
A. Sodium 165 mEq/L
x x x
B. Potassium 5.2 mEq/L
x x x
C. Urine specific gravity 1.020
x x x x
D. Hct 62% - correct answer ✔C Urine specific gravity 1.020
x x x x x x x x x x
Within the expected range of 1.005-1.030
x x x x x
A nurse is monitoring the laboratory findings for a client who is
x x x x x x x x x x x x
postoperative following a total hip arthroplasty 6 hr ago. Which of the
x x x x x x x x x x x x
following values indicates that the client has an increased risk for bleeding
x x x x x x x x x x x
A. PT 11.5 seconds
x x x
B. aPTT 35 seconds
x x x
C. Platelets 80,000
x x
D. RBC 4.0 million - correct answer ✔C Platelets 80,000
x x x x x x x x x
platelet range is 150,000-400,000
x x x
A nurse is admitting a client who has a cervical spinal cord injury following a
x x x x x x x x x x x x x x x
motor vehicle crash. Which of the following interventions is the nurse's
x x x x x x x x x x x
priority while caring for this client
x x x x x
A. Change the client's position every 2 hours
x x x x x x x
, B. Pad pressure points at the edges of the client's cervical collar
x x x x x x x x x x x
C. Palpate the client's abdomen for bladder distention
x x x x x x x
D. Assist the client with quad coughing - correct answer ✔D Assist the client
x x x x x x x x x x x x x x
with quad coughing
x x
The greatest risk to a client who has a cervical spinal cord injury is an
x x x x x x x x x x x x x x x
obstructed airway; the priority is to ensure the client can clear their airway.
x x x x x x x x x x x x x
Apply abdominal pressure as the client coughs (quad coughing)
x x x x x x x x
A nurse is caring for a client who is receiving a blood transfusion. Which of
x x x x x x x x x x x x x x x
the following findings indicates that the client is experiencing transfusion-
x x x x x x x x x
associated circulatory overload x x
A. Nasuea
x
B. Hypothermia
x
C. Dyspnea
x
D. Bradycardia - correct answer ✔C Dyspnea
x x x x x x
Dyspnea is an indication of possible transfusion associated circulatory
x x x x x x x x x
overload, leading to hypertension, bounding pulses, and confusion. Dyspnea
x x x x x x x x x
can also indicate transfusion related acute lung injury to an anaphylactic
x x x x x x x x x x x
response, which also causes wheezing, chest tightness, cyanosis, and low BP
x x x x x x x x x x
A nurse is assessing a client who has lung cancer and is undergoing radiation
x x x x x x x x x x x x x x
therapy to the chest. Which of the following indicates an adverse effect of
x x x x x x x x x x x x x
the therapy
x
A. Hair loss on the scalp
x x x x x
B. Sweating at the treatment site
x x x x x
Assessment 1 with verified solutions
A nurse is teaching a client how to administer a medication using an inhaler
x x x x x x x x x x x x x x
with a spacer. Which of the following instructions should the nurse include
x x x x x x x x x x x
A. "Wait at least 5 minutes between puffs from the same inhaler"
x x x x x x x x x x x
B. "Breathe in rapidly when inhaling the medication"
x x x x x x x
C. "Clean the plastic inhaler cap weekly with cold water"
x x x x x x x x x
D. "Shake the inhaler vigorously prior to use" - correct answer ✔D .) "Shake
x x x x x x x x x x x x x x
the inhaler vigorously prior to use"
x x x x x
Thoroughly shake the inhaler to disperse the medication because the
x x x x x x x x x x
medication in the inhaler can separate easilyx x x x x x
A nurse is planning care for a client who is receiving mechanical ventilation.
x x x x x x x x x x x x x
Which of the following actions should the nurse include in the plan
x x x x x x x x x x x
A. Provide the client with a means of communication
x x x x x x x x
B. Maintain the head of the client's bed in a flat position
x x x x x x x x x x x
C. Suction the client's endotracheal tube every 4 hr
x x x x x x x x
D. Perform oral hygiene for the client every 8 hr - correct answer ✔A.)
x x x x x x x x x x x x x x
Provide the client with a means of communication
x x x x x x x
Use electronic tablet computer, programmable speech generating device,
x x x x x x x x
alphabet board, pencil and paper, etc
x x x x x
,A nurse is caring for a client who is receiving IV fluid replacement therapy for
x x x x x x x x x x x x x x
dehydration. Which of the following laboratory results indicates effectiveness
x x x x x x x x x
of the treatment
x x x
A. Sodium 165 mEq/L
x x x
B. Potassium 5.2 mEq/L
x x x
C. Urine specific gravity 1.020
x x x x
D. Hct 62% - correct answer ✔C Urine specific gravity 1.020
x x x x x x x x x x
Within the expected range of 1.005-1.030
x x x x x
A nurse is monitoring the laboratory findings for a client who is
x x x x x x x x x x x x
postoperative following a total hip arthroplasty 6 hr ago. Which of the
x x x x x x x x x x x x
following values indicates that the client has an increased risk for bleeding
x x x x x x x x x x x
A. PT 11.5 seconds
x x x
B. aPTT 35 seconds
x x x
C. Platelets 80,000
x x
D. RBC 4.0 million - correct answer ✔C Platelets 80,000
x x x x x x x x x
platelet range is 150,000-400,000
x x x
A nurse is admitting a client who has a cervical spinal cord injury following a
x x x x x x x x x x x x x x x
motor vehicle crash. Which of the following interventions is the nurse's
x x x x x x x x x x x
priority while caring for this client
x x x x x
A. Change the client's position every 2 hours
x x x x x x x
, B. Pad pressure points at the edges of the client's cervical collar
x x x x x x x x x x x
C. Palpate the client's abdomen for bladder distention
x x x x x x x
D. Assist the client with quad coughing - correct answer ✔D Assist the client
x x x x x x x x x x x x x x
with quad coughing
x x
The greatest risk to a client who has a cervical spinal cord injury is an
x x x x x x x x x x x x x x x
obstructed airway; the priority is to ensure the client can clear their airway.
x x x x x x x x x x x x x
Apply abdominal pressure as the client coughs (quad coughing)
x x x x x x x x
A nurse is caring for a client who is receiving a blood transfusion. Which of
x x x x x x x x x x x x x x x
the following findings indicates that the client is experiencing transfusion-
x x x x x x x x x
associated circulatory overload x x
A. Nasuea
x
B. Hypothermia
x
C. Dyspnea
x
D. Bradycardia - correct answer ✔C Dyspnea
x x x x x x
Dyspnea is an indication of possible transfusion associated circulatory
x x x x x x x x x
overload, leading to hypertension, bounding pulses, and confusion. Dyspnea
x x x x x x x x x
can also indicate transfusion related acute lung injury to an anaphylactic
x x x x x x x x x x x
response, which also causes wheezing, chest tightness, cyanosis, and low BP
x x x x x x x x x x
A nurse is assessing a client who has lung cancer and is undergoing radiation
x x x x x x x x x x x x x x
therapy to the chest. Which of the following indicates an adverse effect of
x x x x x x x x x x x x x
the therapy
x
A. Hair loss on the scalp
x x x x x
B. Sweating at the treatment site
x x x x x
