Capstone Med Surg Assessment Questions
with Answers and Explanations Complete
Solutions, 100% Correct
Question 1
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
Question 2
A nurse is reviewing the laboratory findings for a client who has a urinary tract
infection. Which of the following laboratory findings should the nurse identify as an
indication the client is in the initial stages of systemic inflammatory response
syndrome (SIRS)?
A. WBC count 14,000/mm
B. Platelets 110,000/ mm
C. Lactic acid 19 mg/dL
D. C reactive protein 2.8 mg/L
Correct Answer
A. ) WBC count 14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms
the body's defenses, resulting in a widespread inflammation. WBCs might increase
initially, but depending on the bone marrow's ability to produce neutrophils and
WBCs, the WBC count can become extremely low
Page 1 of 127
,Question 3
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
available in the client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula
Correct Answer
A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or
decannulation to maintain an airway until a new trach tube can be placed. For the
first 72 hr following the insertion of a trach, dislodgement or decannulation is
considered an emergency
Question 4
A nurse is administering parenteral nutrition to a client who has a history of heart
failure. Which of the following manifestations indicates to the nurse that the client is
experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss
Correct Answer
C
when the client is recumbent, the extracellular fluid enters the vascular system and
increases the blood volume filtering through the kidneys, which increases urine
production
--
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload in a
client who has heart failure
Page 2 of 127
,Question 5
A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the
following findings should the nurse expect
A. lethargy
B. muscle spasms
C. positive chvostek's sign
D. shortened P-R interval
Correct Answer
A. lethargy
12.3 calcium indicates hypercalcemia (range is 9-10.5).
Question 6
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 oversedation
Page 3 of 127
, Question 7
A nurse in a postanesthesia care unit is performing a postoperative assessment on a
client who is recovering from a lumbar laminectomy and has a surgical drain. Which
of the following findings should the nurse identify as a complication of the procedure
A. Clear drainage on the surgical dressing
B. Pain level of 5 on a scale from 0 to 10
C. Reports discomfort when log rolling
D. Drainage output 30m: during the first hour
Correct Answer
A. Clear drainage on the surgical dressing
Clear fluid on or around the surgical dressing following a laminectomy is an
indication of CSF leak. Place the client flat to prevent a spinal headache and notify
provider immediately
Question 8
A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse
notes ventricular tachycardia on the ECG monitor. Which of the following actions
should the nurse take
A. Defibrillate the client
B. Prepare the client for cardioversion
C. Initiate CPR
D. Administer digoxin
Correct Answer
B. Prepare the client for cardioversion
cardioversion is a synchronized countershock that uses a pulse to help convert
vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE
Page 4 of 127
with Answers and Explanations Complete
Solutions, 100% Correct
Question 1
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
Question 2
A nurse is reviewing the laboratory findings for a client who has a urinary tract
infection. Which of the following laboratory findings should the nurse identify as an
indication the client is in the initial stages of systemic inflammatory response
syndrome (SIRS)?
A. WBC count 14,000/mm
B. Platelets 110,000/ mm
C. Lactic acid 19 mg/dL
D. C reactive protein 2.8 mg/L
Correct Answer
A. ) WBC count 14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms
the body's defenses, resulting in a widespread inflammation. WBCs might increase
initially, but depending on the bone marrow's ability to produce neutrophils and
WBCs, the WBC count can become extremely low
Page 1 of 127
,Question 3
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
available in the client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula
Correct Answer
A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or
decannulation to maintain an airway until a new trach tube can be placed. For the
first 72 hr following the insertion of a trach, dislodgement or decannulation is
considered an emergency
Question 4
A nurse is administering parenteral nutrition to a client who has a history of heart
failure. Which of the following manifestations indicates to the nurse that the client is
experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss
Correct Answer
C
when the client is recumbent, the extracellular fluid enters the vascular system and
increases the blood volume filtering through the kidneys, which increases urine
production
--
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload in a
client who has heart failure
Page 2 of 127
,Question 5
A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the
following findings should the nurse expect
A. lethargy
B. muscle spasms
C. positive chvostek's sign
D. shortened P-R interval
Correct Answer
A. lethargy
12.3 calcium indicates hypercalcemia (range is 9-10.5).
Question 6
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 oversedation
Page 3 of 127
, Question 7
A nurse in a postanesthesia care unit is performing a postoperative assessment on a
client who is recovering from a lumbar laminectomy and has a surgical drain. Which
of the following findings should the nurse identify as a complication of the procedure
A. Clear drainage on the surgical dressing
B. Pain level of 5 on a scale from 0 to 10
C. Reports discomfort when log rolling
D. Drainage output 30m: during the first hour
Correct Answer
A. Clear drainage on the surgical dressing
Clear fluid on or around the surgical dressing following a laminectomy is an
indication of CSF leak. Place the client flat to prevent a spinal headache and notify
provider immediately
Question 8
A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse
notes ventricular tachycardia on the ECG monitor. Which of the following actions
should the nurse take
A. Defibrillate the client
B. Prepare the client for cardioversion
C. Initiate CPR
D. Administer digoxin
Correct Answer
B. Prepare the client for cardioversion
cardioversion is a synchronized countershock that uses a pulse to help convert
vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE
Page 4 of 127
