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CAPSTONE ATI NCLEX MEDICAL SURGICAL
ASSESSMENT 1 2025 | COMPREHENSIVE
QUESTIONS WITH VERIFIED ANSWERS
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
B. 1/2 cup cooked navy beans
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C. 1/2 cup cooked asparagus
D. 1/2 cup watermelon - correct-answer-B) 1/2 cup cooked navy beans
navy beans contain 5g of fiber per 1/2 cup
A nurse is providing teaching to a client who has venous insufficiency. Which of
the following statements by the client indicates an understanding of the teaching
A. "I will wear my graduated compression stockings while sleeping"
B. "I will elevate my legs for 10 minutes 3 times per day"
C. "I will limit the time I spend sitting down during the day"
D. "I will cross my legs at my knees when sitting" - correct-answer-C) "I will limit
the time I spend sitting down during the day"
Avoid prolonged periods of sitting or standing, which keeps the legs from being in
a dependent position and helps prevent venous stasis
A nurse is providing teaching to a client who is undergoing radiation therapy and
wants to go for a walk outside. Which of the following recommendations should
the nurse include in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go outdoors"
B. "Gently was the irradiated area to remove the markings before going outside"
C. "Protect exposed skin with an over the counter sunscreen"
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D. "Wear form sitting clothing when going outside" - correct-answer-A) "Try to
avoid sun exposure by waiting until after sunset to go outdoors"
Protect the skin from exposure to sunlight during treatment and for 1 year after
the last treatment. Stay in the shade, go outside in the early morning or evening
to avoid the more intense sun rays to allow the pt to stay outside for a longer
period
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 preparing to obtain blood cultures from a client's central venous
catheter (CVC). Which of the following actions should the nurse take when
accessing the catheter
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A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen - correct-
answer-B) Aspirate for blood return prior to each use
A nurse on a medical surgical unit has received shift report for a group of clients.
Which of the following interventions should the nurse plan to complete first
A. Perform a dressing change on a client who is 24 hr postoperative following
abdominal surgery and has sanguineous drainage on the dressing
B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV
antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is reporting back
pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min - correct-answer-D) Assess a client who is 4hr
postoperative following thoracic surgery and has a respiratory rate of 7/min
Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation
and can indicate respiratory failure or shock, especially in pt who is postop.
CAPSTONE ATI NCLEX MEDICAL SURGICAL
ASSESSMENT 1 2025 | COMPREHENSIVE
QUESTIONS WITH VERIFIED ANSWERS
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
B. 1/2 cup cooked navy beans
,2|Page
C. 1/2 cup cooked asparagus
D. 1/2 cup watermelon - correct-answer-B) 1/2 cup cooked navy beans
navy beans contain 5g of fiber per 1/2 cup
A nurse is providing teaching to a client who has venous insufficiency. Which of
the following statements by the client indicates an understanding of the teaching
A. "I will wear my graduated compression stockings while sleeping"
B. "I will elevate my legs for 10 minutes 3 times per day"
C. "I will limit the time I spend sitting down during the day"
D. "I will cross my legs at my knees when sitting" - correct-answer-C) "I will limit
the time I spend sitting down during the day"
Avoid prolonged periods of sitting or standing, which keeps the legs from being in
a dependent position and helps prevent venous stasis
A nurse is providing teaching to a client who is undergoing radiation therapy and
wants to go for a walk outside. Which of the following recommendations should
the nurse include in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go outdoors"
B. "Gently was the irradiated area to remove the markings before going outside"
C. "Protect exposed skin with an over the counter sunscreen"
,3|Page
D. "Wear form sitting clothing when going outside" - correct-answer-A) "Try to
avoid sun exposure by waiting until after sunset to go outdoors"
Protect the skin from exposure to sunlight during treatment and for 1 year after
the last treatment. Stay in the shade, go outside in the early morning or evening
to avoid the more intense sun rays to allow the pt to stay outside for a longer
period
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 preparing to obtain blood cultures from a client's central venous
catheter (CVC). Which of the following actions should the nurse take when
accessing the catheter
, 4|Page
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen - correct-
answer-B) Aspirate for blood return prior to each use
A nurse on a medical surgical unit has received shift report for a group of clients.
Which of the following interventions should the nurse plan to complete first
A. Perform a dressing change on a client who is 24 hr postoperative following
abdominal surgery and has sanguineous drainage on the dressing
B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV
antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is reporting back
pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min - correct-answer-D) Assess a client who is 4hr
postoperative following thoracic surgery and has a respiratory rate of 7/min
Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation
and can indicate respiratory failure or shock, especially in pt who is postop.
