CAPSTONE ATI NCLEX MEDICAL
SURGICAL
ASSESSMENT 1 EXAM WITH
CORRECT ANSWERS 2025
A nurse is teaching a client how to administer a medication using an
inhaler
spacer. with
Which a of the following instructions should the
nurse include
A. "Wait at least 5 minutes between puffs from the same
B. "Breathe in rapidly when inhaling the
inhaler"
medication"
C. "Clean the plastic inhaler cap weekly with cold
D. "Shake the inhaler vigorously prior to use" ( correct answers ) D .)
water"
"Shake vigorously
inhaler the prior to
Thoroughly shake the inhaler to disperse the medication because the
use"
medication
inhaler in the
can separate
easily
A nurse is planning care for a client who is receiving mechanical
ventilation.
the followingWhich
actions
of 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
C. Suction the client's endotracheal tube
position
every
D. 4 hr oral hygiene for the client every 8 hr
Perform ( correct
answers
client with
) a means of A.) Provide the
communication
Use electronic tablet computer, programmable speech generating
device, alphabet
board, pencil and paper,
etc
A nurse is caring for a client who is receiving IV fluid replacement
therapy for Which of the following laboratory results indicates
dehydration.
effectiveness of the
treatme
nt
A. Sodium 165
B. Potassium 5.2
mEq/L
mEq/L
C. Urine specific gravity
D. Hct 62% ( correct answers )
1.020 C Urine specific
gravitythe
Within 1.020
expected range of 1.005-
1.030
A nurse is monitoring the laboratory findings for a client who is
total hip arthroplasty
postoperative 6 hr
following a ago. Which of the following values indicates that
theincreased
an client hasrisk for
bleeding
GRADED
A+
,A. PT 11.5
B. aPTT 35
seconds
seconds
C. Platelets
D. RBC 4.0 million ( correct answers )
80,000 C Platelets
80,000
platelet range is 150,000-
400,000
A nurse is admitting a client who has a cervical spinal cord injury
following
vehicle crash.
a motor
Which of the following interventions is the nurse's priority
while caring for
this
client
A. Change the client's position every 2
B. Pad pressure points at the edges of the client's
hours
cervical
C. Palpatecollar
the client's abdomen for bladder
D. Assist the client with quad coughing
distention ( correct answers )
quad D Assist the client with
The greatest risk to a client who has a cervical spinal cord injury is an
coughing
obstructed
airway; the priority is to ensure the client can clear their airway. Apply
pressure as the client coughs (quad
abdominal
coughing)
A nurse is caring for a client who is receiving a blood transfusion. Which of
the following
findings indicates that the client is experiencing transfusion-associated
overloa
circulatory
d
A.
B.
Nasuea
C.
Hypothermia
Dyspnea
D. Bradycardia ( correct answers ) C
Dyspnea is an indication of possible transfusion associated circulatory
overload,
to leadingbounding pulses, and confusion. Dyspnea can also indicate
hypertension,
transfusion
related acute lung injury to an anaphylactic response, which also causes
wheezing,
chest tightness, cyanosis, and
low BP
A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an adverse
effect of the therapy
A.
B. Hair loss on
Sweating at the scalp
treatment
C. Altered taste
site
sensations
D. Intolerance to cold ( correct answers ) C
Altered taste is a result of the release of metabolites by dead cells
sensations
A nurse is preparing to administer a unit of packed RBCs to a client who
has anemia. Which of the following actions should the nurse plan to take
(select all that apply)
A. Obtain pre-transfusion
B. Prime the IV tubing with lactated
temperature
Ringer's
GRADED
A+
, C. Instruct an assistive personnel to monitor the client during the
D. Verify the client's blood type with a
transfusion
second
E. Use anurse
20 gauge IV needle for venous access
( correct
A, complete
answers
assessment
) prior to A, D, E
transfusion
D, verify identification, blood compatibility, and expiration of product with
second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to
reduce the risk of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated.
Which of the following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8
C. 18.7
mg/dL
mg/dL
D. 26 mg/dL ( correct answers ) D 26
mg/dL
Normal range is 10-20, and elevated levels indicates renal disease,
excessive protein
dehydration, in the diet, sepsis, glucocorticoid use, GI bleeding, or other
shock,
conditions
in which blood is reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the
following images should the nurse identify as atrial fibrillation
(cannot insert pictures, read
description)
A. multiple irregular and variable waves at the baseline and irregular R to
R intervals
B. a rate of 140-
180/min
C. a tachycardia with no identifiable P wave and is determined to originate
somewhere
other than the ventricles. Rate between 100-
280/min
D. a P wave for every QRS, rate is 60-100/min ( correct
answers ) A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from
the operating
room. Which of the following items is the priority for the nurse to have
client's
availableroom upon
in the
admission
A.
B. Hydrogen
Obturator
C. Sterile
peroxide
gloves
D. Inner cannula ( correct answers ) A.)
Obturator
GRADED
A+
SURGICAL
ASSESSMENT 1 EXAM WITH
CORRECT ANSWERS 2025
A nurse is teaching a client how to administer a medication using an
inhaler
spacer. with
Which a of the following instructions should the
nurse include
A. "Wait at least 5 minutes between puffs from the same
B. "Breathe in rapidly when inhaling the
inhaler"
medication"
C. "Clean the plastic inhaler cap weekly with cold
D. "Shake the inhaler vigorously prior to use" ( correct answers ) D .)
water"
"Shake vigorously
inhaler the prior to
Thoroughly shake the inhaler to disperse the medication because the
use"
medication
inhaler in the
can separate
easily
A nurse is planning care for a client who is receiving mechanical
ventilation.
the followingWhich
actions
of 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
C. Suction the client's endotracheal tube
position
every
D. 4 hr oral hygiene for the client every 8 hr
Perform ( correct
answers
client with
) a means of A.) Provide the
communication
Use electronic tablet computer, programmable speech generating
device, alphabet
board, pencil and paper,
etc
A nurse is caring for a client who is receiving IV fluid replacement
therapy for Which of the following laboratory results indicates
dehydration.
effectiveness of the
treatme
nt
A. Sodium 165
B. Potassium 5.2
mEq/L
mEq/L
C. Urine specific gravity
D. Hct 62% ( correct answers )
1.020 C Urine specific
gravitythe
Within 1.020
expected range of 1.005-
1.030
A nurse is monitoring the laboratory findings for a client who is
total hip arthroplasty
postoperative 6 hr
following a ago. Which of the following values indicates that
theincreased
an client hasrisk for
bleeding
GRADED
A+
,A. PT 11.5
B. aPTT 35
seconds
seconds
C. Platelets
D. RBC 4.0 million ( correct answers )
80,000 C Platelets
80,000
platelet range is 150,000-
400,000
A nurse is admitting a client who has a cervical spinal cord injury
following
vehicle crash.
a motor
Which of the following interventions is the nurse's priority
while caring for
this
client
A. Change the client's position every 2
B. Pad pressure points at the edges of the client's
hours
cervical
C. Palpatecollar
the client's abdomen for bladder
D. Assist the client with quad coughing
distention ( correct answers )
quad D Assist the client with
The greatest risk to a client who has a cervical spinal cord injury is an
coughing
obstructed
airway; the priority is to ensure the client can clear their airway. Apply
pressure as the client coughs (quad
abdominal
coughing)
A nurse is caring for a client who is receiving a blood transfusion. Which of
the following
findings indicates that the client is experiencing transfusion-associated
overloa
circulatory
d
A.
B.
Nasuea
C.
Hypothermia
Dyspnea
D. Bradycardia ( correct answers ) C
Dyspnea is an indication of possible transfusion associated circulatory
overload,
to leadingbounding pulses, and confusion. Dyspnea can also indicate
hypertension,
transfusion
related acute lung injury to an anaphylactic response, which also causes
wheezing,
chest tightness, cyanosis, and
low BP
A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an adverse
effect of the therapy
A.
B. Hair loss on
Sweating at the scalp
treatment
C. Altered taste
site
sensations
D. Intolerance to cold ( correct answers ) C
Altered taste is a result of the release of metabolites by dead cells
sensations
A nurse is preparing to administer a unit of packed RBCs to a client who
has anemia. Which of the following actions should the nurse plan to take
(select all that apply)
A. Obtain pre-transfusion
B. Prime the IV tubing with lactated
temperature
Ringer's
GRADED
A+
, C. Instruct an assistive personnel to monitor the client during the
D. Verify the client's blood type with a
transfusion
second
E. Use anurse
20 gauge IV needle for venous access
( correct
A, complete
answers
assessment
) prior to A, D, E
transfusion
D, verify identification, blood compatibility, and expiration of product with
second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to
reduce the risk of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated.
Which of the following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8
C. 18.7
mg/dL
mg/dL
D. 26 mg/dL ( correct answers ) D 26
mg/dL
Normal range is 10-20, and elevated levels indicates renal disease,
excessive protein
dehydration, in the diet, sepsis, glucocorticoid use, GI bleeding, or other
shock,
conditions
in which blood is reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the
following images should the nurse identify as atrial fibrillation
(cannot insert pictures, read
description)
A. multiple irregular and variable waves at the baseline and irregular R to
R intervals
B. a rate of 140-
180/min
C. a tachycardia with no identifiable P wave and is determined to originate
somewhere
other than the ventricles. Rate between 100-
280/min
D. a P wave for every QRS, rate is 60-100/min ( correct
answers ) A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from
the operating
room. Which of the following items is the priority for the nurse to have
client's
availableroom upon
in the
admission
A.
B. Hydrogen
Obturator
C. Sterile
peroxide
gloves
D. Inner cannula ( correct answers ) A.)
Obturator
GRADED
A+
