1|Page
Capstone ATI NCLEX Medical Surgical Exam Newest 2025
Actual Exam| Complete Questions and Correct Detailed
Answers (Verified Answers with Rationales) Already Graded
A+||New!!
A nurse is monitoring a client who is receiving moderate sedation with
midazolam. Which of the following findings requires immediate
intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea - Correct Answer - B) No response to verbal stimuli
using urgent vs non-urgent approach, this is the priority. During
moderate sedation, the pt should be able to provide a response to
questions and commands. No response to verbal stimuli can indicate a
loss or consciousness or over sedation
A nurse is reviewing the laboratory findings for a client who has heart
failure and is taking furosemide. The nurse should identify which of the
following findings as an adverse effect of the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia - Correct Answer - C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys,
causing an increased excretion of potassium. Monitor for dysrhythmias
pg. 1
,2|Page
A nurse is caring for a client who is in Buck's traction. Which of the
following actions should the nurse take? (select all that apply)
A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction blood
E. Assess the temperature of the affected extremity - Correct Answer - A,
D, E
A, closely monitor the neurovascular integrity. Circulation can be
compromised from the fracture as well as the traction device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well as the
traction device. Check and document color, temperature, distal pulses,
capillary refill, movement, and sensation during neurovascular
assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure,
paresthesia, and paralysis
A nurse is reviewing safety measures with the caregiver of a client who
has Alzheimer's disease. Which of the following instructions should the
nurse include in the teaching
A. Lock doors leading to stairways
B. Instruct the client not to use the stove
C. Place a throw rug in front of the toilet
D. Provide a darkened room for the client to sleep - Correct Answer - A)
Lock doors leading to stairways
pg. 2
,3|Page
This pt is at an increased risk for falls d/t difficulty with balance and an
inability to recognize dangerous situations due to brain damage from the
disease
A nurse in an emergency department is monitoring a client who reports
angina. Which of the following findings should indicate to the nurse that
the client might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - Correct Answer - A) Increased
troponin
Troponin is a myocardial muscle protein released into the blood stream
as a result of injury to the heart muscle. Troponin levels increase within
2-3 hr following an MI
A nurse is caring for a client who has a right subclavian central venous
catheter. Which reconnecting a new intravenous infusion administration
set, which of the following actions should the nurse take
A. Ask the client to exhale slowly
B. Turn the client's head to the right
C. Place the client in a semi fowlers position
D. use aseptic technique - Correct Answer - D use aseptic technique
aseptic= sterile
prevents central line related blood infections when disconnecting and
reconnecting the new set
pg. 3
, 4|Page
A nurse is educating an older adult client about immunizations. Which
of the following immunizations should the nurse include in the
recommendation for the client
A. Recombinant herpes zoster
B. Human papillomavirus
C. Live attenuated influenza
D. Varicella - Correct Answer - A) Recombinant herpes zoster
herpes zoster= shingles
Older adults can get either the live or recombinant herpes zoster
immunization
A nurse is administering epinephrine IV to a client who is having an
anaphylactic reaction. Which of the following findings should the nurse
identify as a therapeutic response to the medication
A. Hypoglycemia
B. Thickened bronchial secretions
C. Regular heart rate with hypotension
D. Non-itchy skin wheals - Correct Answer - D) Non-itchy skin wheals
A pt in anaphylactic shock can experience intensely itchy skin with
wheals or hives that can merge to form large red blotches. Epi blocks the
release of histamine and decreases erythema, angioedema, and hives
A nurse is assisting in selecting foods for lunch with a client who has
diverticulosis. Which of the following foods should the nurse
recommend as the best source of fiber
A. 1 slice of rye bread
pg. 4
Capstone ATI NCLEX Medical Surgical Exam Newest 2025
Actual Exam| Complete Questions and Correct Detailed
Answers (Verified Answers with Rationales) Already Graded
A+||New!!
A nurse is monitoring a client who is receiving moderate sedation with
midazolam. Which of the following findings requires immediate
intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea - Correct Answer - B) No response to verbal stimuli
using urgent vs non-urgent approach, this is the priority. During
moderate sedation, the pt should be able to provide a response to
questions and commands. No response to verbal stimuli can indicate a
loss or consciousness or over sedation
A nurse is reviewing the laboratory findings for a client who has heart
failure and is taking furosemide. The nurse should identify which of the
following findings as an adverse effect of the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia - Correct Answer - C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys,
causing an increased excretion of potassium. Monitor for dysrhythmias
pg. 1
,2|Page
A nurse is caring for a client who is in Buck's traction. Which of the
following actions should the nurse take? (select all that apply)
A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction blood
E. Assess the temperature of the affected extremity - Correct Answer - A,
D, E
A, closely monitor the neurovascular integrity. Circulation can be
compromised from the fracture as well as the traction device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well as the
traction device. Check and document color, temperature, distal pulses,
capillary refill, movement, and sensation during neurovascular
assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure,
paresthesia, and paralysis
A nurse is reviewing safety measures with the caregiver of a client who
has Alzheimer's disease. Which of the following instructions should the
nurse include in the teaching
A. Lock doors leading to stairways
B. Instruct the client not to use the stove
C. Place a throw rug in front of the toilet
D. Provide a darkened room for the client to sleep - Correct Answer - A)
Lock doors leading to stairways
pg. 2
,3|Page
This pt is at an increased risk for falls d/t difficulty with balance and an
inability to recognize dangerous situations due to brain damage from the
disease
A nurse in an emergency department is monitoring a client who reports
angina. Which of the following findings should indicate to the nurse that
the client might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - Correct Answer - A) Increased
troponin
Troponin is a myocardial muscle protein released into the blood stream
as a result of injury to the heart muscle. Troponin levels increase within
2-3 hr following an MI
A nurse is caring for a client who has a right subclavian central venous
catheter. Which reconnecting a new intravenous infusion administration
set, which of the following actions should the nurse take
A. Ask the client to exhale slowly
B. Turn the client's head to the right
C. Place the client in a semi fowlers position
D. use aseptic technique - Correct Answer - D use aseptic technique
aseptic= sterile
prevents central line related blood infections when disconnecting and
reconnecting the new set
pg. 3
, 4|Page
A nurse is educating an older adult client about immunizations. Which
of the following immunizations should the nurse include in the
recommendation for the client
A. Recombinant herpes zoster
B. Human papillomavirus
C. Live attenuated influenza
D. Varicella - Correct Answer - A) Recombinant herpes zoster
herpes zoster= shingles
Older adults can get either the live or recombinant herpes zoster
immunization
A nurse is administering epinephrine IV to a client who is having an
anaphylactic reaction. Which of the following findings should the nurse
identify as a therapeutic response to the medication
A. Hypoglycemia
B. Thickened bronchial secretions
C. Regular heart rate with hypotension
D. Non-itchy skin wheals - Correct Answer - D) Non-itchy skin wheals
A pt in anaphylactic shock can experience intensely itchy skin with
wheals or hives that can merge to form large red blotches. Epi blocks the
release of histamine and decreases erythema, angioedema, and hives
A nurse is assisting in selecting foods for lunch with a client who has
diverticulosis. Which of the following foods should the nurse
recommend as the best source of fiber
A. 1 slice of rye bread
pg. 4
