CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1, ATI
CAPSTONE ADULT MEDICAL
SURGICAL ASSESSMENT 2 EXAM
QUESTIONS AND DETAILED
ANSWERS
A nurse is teaching a client how to administer a medication using an
inhaler with a spacer. Which of the following instructions should the
nurse include
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use" - ANSWER- D .) "Shake
the inhaler vigorously prior to use"
,Thoroughly shake the inhaler to disperse the medication because the
medication in the inhaler can separate easily
A nurse is planning care for a client who is receiving mechanical
ventilation. Which of the following actions should the nurse include in
the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - ANSWER- A.)
Provide the client with a means of communication
Use electronic tablet computer, programmable speech generating
device, alphabet board, pencil and paper, etc
A nurse is caring for a client who is receiving IV fluid replacement
therapy for dehydration. Which of the following laboratory results
indicates effectiveness of the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER- C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
,A nurse is monitoring the laboratory findings for a client who is
postoperative following a total hip arthroplasty 6 hr ago. Which of the
following values indicates that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - ANSWER- C Platelets 80,000
platelet range is 150,000-400,000
A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following interventions is
the nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - ANSWER- D Assist the client
with quad coughing
The greatest risk to a client who has a cervical spinal cord injury is
an obstructed airway; the priority is to ensure the client can clear
their airway. Apply abdominal pressure as the client coughs (quad
coughing)
, A nurse is caring for a client who is receiving a blood transfusion.
Which of the following findings indicates that the client is experiencing
transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - ANSWER- C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses, and
confusion. Dyspnea can also indicate transfusion related acute lung
injury to an anaphylactic response, which also causes wheezing,
chest tightness, cyanosis, and low BP
A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an
adverse effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold - ANSWER- C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
SURGICAL ASSESSMENT 1, ATI
CAPSTONE ADULT MEDICAL
SURGICAL ASSESSMENT 2 EXAM
QUESTIONS AND DETAILED
ANSWERS
A nurse is teaching a client how to administer a medication using an
inhaler with a spacer. Which of the following instructions should the
nurse include
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use" - ANSWER- D .) "Shake
the inhaler vigorously prior to use"
,Thoroughly shake the inhaler to disperse the medication because the
medication in the inhaler can separate easily
A nurse is planning care for a client who is receiving mechanical
ventilation. Which of the following actions should the nurse include in
the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - ANSWER- A.)
Provide the client with a means of communication
Use electronic tablet computer, programmable speech generating
device, alphabet board, pencil and paper, etc
A nurse is caring for a client who is receiving IV fluid replacement
therapy for dehydration. Which of the following laboratory results
indicates effectiveness of the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER- C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
,A nurse is monitoring the laboratory findings for a client who is
postoperative following a total hip arthroplasty 6 hr ago. Which of the
following values indicates that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - ANSWER- C Platelets 80,000
platelet range is 150,000-400,000
A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following interventions is
the nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - ANSWER- D Assist the client
with quad coughing
The greatest risk to a client who has a cervical spinal cord injury is
an obstructed airway; the priority is to ensure the client can clear
their airway. Apply abdominal pressure as the client coughs (quad
coughing)
, A nurse is caring for a client who is receiving a blood transfusion.
Which of the following findings indicates that the client is experiencing
transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - ANSWER- C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses, and
confusion. Dyspnea can also indicate transfusion related acute lung
injury to an anaphylactic response, which also causes wheezing,
chest tightness, cyanosis, and low BP
A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an
adverse effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold - ANSWER- C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
