MED SURG ATI CAPSTONE QUESTIONS
AND ANSWERS GRADED A+
y A nurse on a med surg unit is caring for a group of clients. The nurse should notify the rapid response
team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse - B
A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the
nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids - B, C, E
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is
unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that
apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - A, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner states, "He was pulling
weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use
to open the client's airway?
, A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - A
A nurse is reviewing the common emergency management protocol for clients who have asystole. Which
of the following actions should the nurse plan to take during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities - C
A nurse is caring for a client who is postprocedural following LP and reports throbbing headache when
sitting upright. Which of the following actions should the nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises - B, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the
following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - B
A nurse is assessing a client for changes in the level of consciousness using the GCS. The client opens his
eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the
following GCS scores should the nurse document?
AND ANSWERS GRADED A+
y A nurse on a med surg unit is caring for a group of clients. The nurse should notify the rapid response
team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse - B
A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the
nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids - B, C, E
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is
unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that
apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - A, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner states, "He was pulling
weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use
to open the client's airway?
, A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - A
A nurse is reviewing the common emergency management protocol for clients who have asystole. Which
of the following actions should the nurse plan to take during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer IV epinephrine
D. Elevate the client's lower extremities - C
A nurse is caring for a client who is postprocedural following LP and reports throbbing headache when
sitting upright. Which of the following actions should the nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises - B, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the
following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - B
A nurse is assessing a client for changes in the level of consciousness using the GCS. The client opens his
eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the
following GCS scores should the nurse document?
