CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 QUESTIONS
AND ANSWERS
A bnurse bis bteaching ba bclient bhow bto badminister ba bmedication busing ban binhaler
bwith ba bspacer. bWhich bof bthe bfollowing binstructions bshould bthe bnurse binclude
A. b"Wait bat bleast b5 bminutes bbetween bpuffs bfrom bthe bsame binhaler"
B. b"Breathe bin brapidly bwhen binhaling bthe bmedication"
C. b"Clean bthe bplastic binhaler bcap bweekly bwith bcold bwater"
D. b"Shake bthe binhaler bvigorously bprior bto buse" b- bcorrect banswer✔✔D b.) b"Shake
bthe binhaler bvigorously bprior bto buse"
Thoroughly bshake bthe binhaler bto bdisperse bthe bmedication bbecause bthe bmedication
bin bthe binhaler bcan bseparate beasily
A bnurse bis bplanning bcare bfor ba bclient bwho bis breceiving bmechanical bventilation.
bWhich bof bthe bfollowing bactions bshould bthe bnurse binclude bin bthe bplan
A. bProvide bthe bclient bwith ba bmeans bof bcommunication
B. bMaintain bthe bhead bof bthe bclient's bbed bin ba bflat bposition
C. bSuction bthe bclient's bendotracheal btube bevery b4 bhr
D. bPerform boral bhygiene bfor bthe bclient bevery b8 bhr b- bcorrect banswer✔✔A.) bProvide
bthe bclient bwith ba bmeans bof bcommunication
Use belectronic btablet bcomputer, bprogrammable bspeech bgenerating bdevice, balphabet
bboard, bpencil band bpaper, betc
A bnurse bis bcaring bfor ba bclient bwho bis breceiving bIV bfluid breplacement btherapy bfor
bdehydration. bWhich bof bthe bfollowing blaboratory bresults bindicates beffectiveness bof
bthe btreatment
A. bSodium b165 bmEq/L
B. bPotassium b5.2 bmEq/L
C. bUrine bspecific bgravity b1.020
,D. bHct b62% b- bcorrect banswer✔✔C bUrine bspecific bgravity b1.020
Within bthe bexpected brange bof b1.005-1.030
A bnurse bis bmonitoring bthe blaboratory bfindings bfor ba bclient bwho bis bpostoperative
bfollowing ba btotal bhip barthroplasty b6 bhr bago. bWhich bof bthe bfollowing bvalues
bindicates bthat bthe bclient bhas ban bincreased brisk bfor bbleeding
A. bPT b11.5 bseconds
B. baPTT b35 bseconds
C. bPlatelets b80,000
D. bRBC b4.0 bmillion b- bcorrect banswer✔✔C bPlatelets b80,000
platelet brange bis b150,000-400,000
A bnurse bis badmitting ba bclient bwho bhas ba bcervical bspinal bcord binjury bfollowing ba
bmotor bvehicle bcrash. bWhich bof bthe bfollowing binterventions bis bthe bnurse's bpriority
bwhile bcaring bfor bthis bclient
A. bChange bthe bclient's bposition bevery b2 bhours
B. bPad bpressure bpoints bat bthe bedges bof bthe bclient's bcervical bcollar
C. bPalpate bthe bclient's babdomen bfor bbladder bdistention
D. bAssist bthe bclient bwith bquad bcoughing b- bcorrect banswer✔✔D bAssist bthe bclient
bwith bquad bcoughing
The bgreatest brisk bto ba bclient bwho bhas ba bcervical bspinal bcord binjury bis ban
bobstructed bairway; bthe bpriority bis bto bensure bthe bclient bcan bclear btheir bairway.
bApply babdominal bpressure bas bthe bclient bcoughs b(quad bcoughing)
A bnurse bis bcaring bfor ba bclient bwho bis breceiving ba bblood btransfusion. bWhich bof bthe
bfollowing bfindings bindicates bthat bthe bclient bis bexperiencing btransfusion-associated
bcirculatory boverload
A. bNasuea
B. bHypothermia
C. bDyspnea
D. bBradycardia b- bcorrect banswer✔✔C bDyspnea
Dyspnea bis ban bindication bof bpossible btransfusion bassociated bcirculatory boverload,
bleading bto bhypertension, bbounding bpulses, band bconfusion. bDyspnea bcan balso
bindicate btransfusion brelated bacute blung binjury bto ban banaphylactic bresponse, bwhich
balso bcauses bwheezing, bchest btightness, bcyanosis, band blow bBP
A bnurse bis bassessing ba bclient bwho bhas blung bcancer band bis bundergoing bradiation
btherapy bto bthe bchest. bWhich bof bthe bfollowing bindicates ban badverse beffect bof bthe
btherapy
A. bHair bloss bon bthe bscalp
B. bSweating bat bthe btreatment bsite
C. bAltered btaste bsensations
, D. bIntolerance bto bcold b- bcorrect banswer✔✔C bAltered btaste bsensations
Altered btaste bis ba bresult bof bthe brelease bof bmetabolites bby bdead bcells
A bnurse bis bpreparing bto badminister ba bunit bof bpacked bRBCs bto ba bclient bwho bhas
banemia. bWhich bof bthe bfollowing bactions bshould bthe bnurse bplan bto btake b(select ball
bthat bapply)
A. bObtain bpre-transfusion btemperature
B. bPrime bthe bIV btubing bwith blactated bRinger's
C. bInstruct ban bassistive bpersonnel bto bmonitor bthe bclient bduring bthe btransfusion
D. bVerify bthe bclient's bblood btype bwith ba bsecond bnurse
E. bUse ba b20 bgauge bIV bneedle bfor bvenous baccess b- bcorrect banswer✔✔A, bD, bE
A, bcomplete bassessment bprior bto btransfusion
D, bverify bidentification, bblood bcompatibility, band bexpiration bof bproduct bwith bsecond
bnurse b
E, bthe bnurse bshould buse ba blarge bbore bneedle bto btransfuse bthe bPRBCs bto breduce
bthe brisk bof bcell bhemolysis band bobstruction bof bflow
A bnurse bis breviewing bthe blaboratory bfindings bfor ba bclient bwho bis bdehydrated.
bWhich bof bthe bfollowing bBUN blevels bshould bthe bnurse bexpect
A. b3.6 bmg/dl
B. b8 bmg/dL
C. b18.7 bmg/dL
D. b26 bmg/dL b- bcorrect banswer✔✔D b26 bmg/dL
Normal brange bis b10-20, band belevated blevels bindicates brenal bdisease, bdehydration,
bshock, bexcessive bprotein bin bthe bdiet, bsepsis, bglucocorticoid buse, bGI bbleeding, bor
bother bconditions bin bwhich bblood bis breabsorbed bfrom binjured btissues
A bnurse bis breviewing bECG bstrips bfor bseveral bclients. bWhich bof bthe bfollowing
bimages bshould bthe bnurse bidentify bas batrial bfibrillation
(cannot binsert bpictures, bread bdescription)
A. bmultiple birregular band bvariable bwaves bat bthe bbaseline band birregular bR bto bR
bintervals
B. ba brate bof b140-180/min
C. ba btachycardia bwith bno bidentifiable bP bwave band bis bdetermined bto boriginate
bsomewhere bother bthan bthe bventricles. bRate bbetween b100-280/min
SURGICAL ASSESSMENT 1 QUESTIONS
AND ANSWERS
A bnurse bis bteaching ba bclient bhow bto badminister ba bmedication busing ban binhaler
bwith ba bspacer. bWhich bof bthe bfollowing binstructions bshould bthe bnurse binclude
A. b"Wait bat bleast b5 bminutes bbetween bpuffs bfrom bthe bsame binhaler"
B. b"Breathe bin brapidly bwhen binhaling bthe bmedication"
C. b"Clean bthe bplastic binhaler bcap bweekly bwith bcold bwater"
D. b"Shake bthe binhaler bvigorously bprior bto buse" b- bcorrect banswer✔✔D b.) b"Shake
bthe binhaler bvigorously bprior bto buse"
Thoroughly bshake bthe binhaler bto bdisperse bthe bmedication bbecause bthe bmedication
bin bthe binhaler bcan bseparate beasily
A bnurse bis bplanning bcare bfor ba bclient bwho bis breceiving bmechanical bventilation.
bWhich bof bthe bfollowing bactions bshould bthe bnurse binclude bin bthe bplan
A. bProvide bthe bclient bwith ba bmeans bof bcommunication
B. bMaintain bthe bhead bof bthe bclient's bbed bin ba bflat bposition
C. bSuction bthe bclient's bendotracheal btube bevery b4 bhr
D. bPerform boral bhygiene bfor bthe bclient bevery b8 bhr b- bcorrect banswer✔✔A.) bProvide
bthe bclient bwith ba bmeans bof bcommunication
Use belectronic btablet bcomputer, bprogrammable bspeech bgenerating bdevice, balphabet
bboard, bpencil band bpaper, betc
A bnurse bis bcaring bfor ba bclient bwho bis breceiving bIV bfluid breplacement btherapy bfor
bdehydration. bWhich bof bthe bfollowing blaboratory bresults bindicates beffectiveness bof
bthe btreatment
A. bSodium b165 bmEq/L
B. bPotassium b5.2 bmEq/L
C. bUrine bspecific bgravity b1.020
,D. bHct b62% b- bcorrect banswer✔✔C bUrine bspecific bgravity b1.020
Within bthe bexpected brange bof b1.005-1.030
A bnurse bis bmonitoring bthe blaboratory bfindings bfor ba bclient bwho bis bpostoperative
bfollowing ba btotal bhip barthroplasty b6 bhr bago. bWhich bof bthe bfollowing bvalues
bindicates bthat bthe bclient bhas ban bincreased brisk bfor bbleeding
A. bPT b11.5 bseconds
B. baPTT b35 bseconds
C. bPlatelets b80,000
D. bRBC b4.0 bmillion b- bcorrect banswer✔✔C bPlatelets b80,000
platelet brange bis b150,000-400,000
A bnurse bis badmitting ba bclient bwho bhas ba bcervical bspinal bcord binjury bfollowing ba
bmotor bvehicle bcrash. bWhich bof bthe bfollowing binterventions bis bthe bnurse's bpriority
bwhile bcaring bfor bthis bclient
A. bChange bthe bclient's bposition bevery b2 bhours
B. bPad bpressure bpoints bat bthe bedges bof bthe bclient's bcervical bcollar
C. bPalpate bthe bclient's babdomen bfor bbladder bdistention
D. bAssist bthe bclient bwith bquad bcoughing b- bcorrect banswer✔✔D bAssist bthe bclient
bwith bquad bcoughing
The bgreatest brisk bto ba bclient bwho bhas ba bcervical bspinal bcord binjury bis ban
bobstructed bairway; bthe bpriority bis bto bensure bthe bclient bcan bclear btheir bairway.
bApply babdominal bpressure bas bthe bclient bcoughs b(quad bcoughing)
A bnurse bis bcaring bfor ba bclient bwho bis breceiving ba bblood btransfusion. bWhich bof bthe
bfollowing bfindings bindicates bthat bthe bclient bis bexperiencing btransfusion-associated
bcirculatory boverload
A. bNasuea
B. bHypothermia
C. bDyspnea
D. bBradycardia b- bcorrect banswer✔✔C bDyspnea
Dyspnea bis ban bindication bof bpossible btransfusion bassociated bcirculatory boverload,
bleading bto bhypertension, bbounding bpulses, band bconfusion. bDyspnea bcan balso
bindicate btransfusion brelated bacute blung binjury bto ban banaphylactic bresponse, bwhich
balso bcauses bwheezing, bchest btightness, bcyanosis, band blow bBP
A bnurse bis bassessing ba bclient bwho bhas blung bcancer band bis bundergoing bradiation
btherapy bto bthe bchest. bWhich bof bthe bfollowing bindicates ban badverse beffect bof bthe
btherapy
A. bHair bloss bon bthe bscalp
B. bSweating bat bthe btreatment bsite
C. bAltered btaste bsensations
, D. bIntolerance bto bcold b- bcorrect banswer✔✔C bAltered btaste bsensations
Altered btaste bis ba bresult bof bthe brelease bof bmetabolites bby bdead bcells
A bnurse bis bpreparing bto badminister ba bunit bof bpacked bRBCs bto ba bclient bwho bhas
banemia. bWhich bof bthe bfollowing bactions bshould bthe bnurse bplan bto btake b(select ball
bthat bapply)
A. bObtain bpre-transfusion btemperature
B. bPrime bthe bIV btubing bwith blactated bRinger's
C. bInstruct ban bassistive bpersonnel bto bmonitor bthe bclient bduring bthe btransfusion
D. bVerify bthe bclient's bblood btype bwith ba bsecond bnurse
E. bUse ba b20 bgauge bIV bneedle bfor bvenous baccess b- bcorrect banswer✔✔A, bD, bE
A, bcomplete bassessment bprior bto btransfusion
D, bverify bidentification, bblood bcompatibility, band bexpiration bof bproduct bwith bsecond
bnurse b
E, bthe bnurse bshould buse ba blarge bbore bneedle bto btransfuse bthe bPRBCs bto breduce
bthe brisk bof bcell bhemolysis band bobstruction bof bflow
A bnurse bis breviewing bthe blaboratory bfindings bfor ba bclient bwho bis bdehydrated.
bWhich bof bthe bfollowing bBUN blevels bshould bthe bnurse bexpect
A. b3.6 bmg/dl
B. b8 bmg/dL
C. b18.7 bmg/dL
D. b26 bmg/dL b- bcorrect banswer✔✔D b26 bmg/dL
Normal brange bis b10-20, band belevated blevels bindicates brenal bdisease, bdehydration,
bshock, bexcessive bprotein bin bthe bdiet, bsepsis, bglucocorticoid buse, bGI bbleeding, bor
bother bconditions bin bwhich bblood bis breabsorbed bfrom binjured btissues
A bnurse bis breviewing bECG bstrips bfor bseveral bclients. bWhich bof bthe bfollowing
bimages bshould bthe bnurse bidentify bas batrial bfibrillation
(cannot binsert bpictures, bread bdescription)
A. bmultiple birregular band bvariable bwaves bat bthe bbaseline band birregular bR bto bR
bintervals
B. ba brate bof b140-180/min
C. ba btachycardia bwith bno bidentifiable bP bwave band bis bdetermined bto boriginate
bsomewhere bother bthan bthe bventricles. bRate bbetween b100-280/min
