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