Med Surg ATI Capstone, ATI NCLEX Medical
Surgical Assessment 1, Med surg 22026/2027 –
Questions & Verified Solutions
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 -
ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ANSWERS-B
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the
client should the nurse report to the provider? (Select all that apply)
, A. "I think I might be pregnant"
B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" - ANSWERS-A, B, D, E
A nurse is providing education to a client who is to undergo an EEG the next
day. Which of the following information should the nurse include in the
teaching?
A. "Do not wash your hair the morning of the procedure"
B. "Try to stay awake most of the night prior to the procedure"
C. "The procedure will take approximately 15 minutes"
D. "You will need to lie flat for 4 hours after the procedure" - ANSWERS-B
A nurse is assessing a client who reports severe headache and a stiff neck.
The nurse's assessment reveals positive Kernig's and Brudzinski's signs.
Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights - ANSWERS-B
A nurse is assessing for the presence of Brudzinski's sign in a client who has
suspected meningitis. Which of the following actions should the nurse take
when performing this technique? (Select all that apply)
Surgical Assessment 1, Med surg 22026/2027 –
Questions & Verified Solutions
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 -
ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ANSWERS-B
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the
client should the nurse report to the provider? (Select all that apply)
, A. "I think I might be pregnant"
B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" - ANSWERS-A, B, D, E
A nurse is providing education to a client who is to undergo an EEG the next
day. Which of the following information should the nurse include in the
teaching?
A. "Do not wash your hair the morning of the procedure"
B. "Try to stay awake most of the night prior to the procedure"
C. "The procedure will take approximately 15 minutes"
D. "You will need to lie flat for 4 hours after the procedure" - ANSWERS-B
A nurse is assessing a client who reports severe headache and a stiff neck.
The nurse's assessment reveals positive Kernig's and Brudzinski's signs.
Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights - ANSWERS-B
A nurse is assessing for the presence of Brudzinski's sign in a client who has
suspected meningitis. Which of the following actions should the nurse take
when performing this technique? (Select all that apply)
