Capstone ATI NCLEX Medical Surgical
Assessment 1 Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A client with COPD is receiving oxygen via nasal cannula at 4 L/min. Which action should the
nurse take first?
A. Encourage pursed-lip breathing
✔✔ B. Reduce the oxygen flow rate
C. Assess temperature
D. Elevate the client's legs
A nurse is caring for a client post-hip replacement who suddenly complains of shortness of
breath and chest pain. What should the nurse suspect?
✔✔ A. Pulmonary embolism
B. Myocardial infarction
C. Atelectasis
D. Pneumonia
1
,A nurse is assessing a client with left-sided heart failure. Which finding should be reported
immediately?
A. Fatigue and weakness
B. Nocturia
✔✔ C. Frothy pink sputum
D. Cool extremities
Which food should be avoided by a client taking warfarin?
✔✔ A. Spinach
B. Chicken breast
C. Bananas
D. Applesauce
A client with diabetes has a fasting glucose of 64 mg/dL. Which action should the nurse take?
✔✔ A. Administer 15g of glucose
B. Notify the provider
C. Recheck in 2 hours
D. Give sliding scale insulin
2
,A nurse is monitoring a client following thyroidectomy. Which finding should be reported
immediately?
A. Hoarse voice
✔✔ B. Tingling around the mouth
C. Pain at the incision site
D. Slight swelling around the neck
A client with a DVT is receiving IV heparin. Which lab result requires intervention?
A. INR 1.1
✔✔ B. aPTT 110 seconds
C. Platelets 200,000
D. Hemoglobin 13.4
A nurse is caring for a client with cirrhosis who is at risk for hepatic encephalopathy. Which
dietary instruction is appropriate?
✔✔ A. Reduce protein intake
B. Increase calcium
3
, C. Limit carbohydrates
D. Avoid sodium
A client receiving chemotherapy reports mouth sores and difficulty eating. What should the nurse
recommend?
A. Use mouthwash with alcohol
✔✔ B. Rinse mouth with saline
C. Eat spicy foods to stimulate taste
D. Brush teeth with firm-bristled brush
A nurse is assessing a client with peritonitis. Which finding requires immediate action?
A. Nausea and vomiting
B. Firm abdomen
✔✔ C. Absent bowel sounds
D. Fever of 38.1°C (100.6°F)
Which of the following clients is at highest risk for skin breakdown?
A. Ambulatory with urinary incontinence
4
Assessment 1 Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A client with COPD is receiving oxygen via nasal cannula at 4 L/min. Which action should the
nurse take first?
A. Encourage pursed-lip breathing
✔✔ B. Reduce the oxygen flow rate
C. Assess temperature
D. Elevate the client's legs
A nurse is caring for a client post-hip replacement who suddenly complains of shortness of
breath and chest pain. What should the nurse suspect?
✔✔ A. Pulmonary embolism
B. Myocardial infarction
C. Atelectasis
D. Pneumonia
1
,A nurse is assessing a client with left-sided heart failure. Which finding should be reported
immediately?
A. Fatigue and weakness
B. Nocturia
✔✔ C. Frothy pink sputum
D. Cool extremities
Which food should be avoided by a client taking warfarin?
✔✔ A. Spinach
B. Chicken breast
C. Bananas
D. Applesauce
A client with diabetes has a fasting glucose of 64 mg/dL. Which action should the nurse take?
✔✔ A. Administer 15g of glucose
B. Notify the provider
C. Recheck in 2 hours
D. Give sliding scale insulin
2
,A nurse is monitoring a client following thyroidectomy. Which finding should be reported
immediately?
A. Hoarse voice
✔✔ B. Tingling around the mouth
C. Pain at the incision site
D. Slight swelling around the neck
A client with a DVT is receiving IV heparin. Which lab result requires intervention?
A. INR 1.1
✔✔ B. aPTT 110 seconds
C. Platelets 200,000
D. Hemoglobin 13.4
A nurse is caring for a client with cirrhosis who is at risk for hepatic encephalopathy. Which
dietary instruction is appropriate?
✔✔ A. Reduce protein intake
B. Increase calcium
3
, C. Limit carbohydrates
D. Avoid sodium
A client receiving chemotherapy reports mouth sores and difficulty eating. What should the nurse
recommend?
A. Use mouthwash with alcohol
✔✔ B. Rinse mouth with saline
C. Eat spicy foods to stimulate taste
D. Brush teeth with firm-bristled brush
A nurse is assessing a client with peritonitis. Which finding requires immediate action?
A. Nausea and vomiting
B. Firm abdomen
✔✔ C. Absent bowel sounds
D. Fever of 38.1°C (100.6°F)
Which of the following clients is at highest risk for skin breakdown?
A. Ambulatory with urinary incontinence
4
