Capstone ATI NCLEX Medical
Surgical Assessment 1 & 2 – Complete
Exam (160 Questions)
1. A nurse is educating a group of clients about menopause. Which of the
following information should the nurse include?
A. Limit exercise to 30 min, one to two times a week to reduce fatigue
B. Hormone therapy (HT) is no longer used because of the risk of cancer
C. Vaginal bleeding after 1 year without menses should be reported to the
provider
D. The use of complementary therapies to treat hot flashes should be
avoided
Correct Answer: C
Rationale: Any vaginal bleeding occurring 1 year after menses have stopped
should be reported to the provider because it can indicate a malignant process, not
just menopause. Vaginal bleeding after 1 year without menses should be
reported to the provider (C).
2. A nurse is reviewing the medical record of a client who is to undergo a
surgical procedure. Which of the following findings indicates that the client
is at risk for developing DVT?
A. BMI 38.6
B. History of asthma
C. Use of glucosamine sulfate
D. Hypothyroidism
Correct Answer: A
Rationale: A BMI of 38.6 indicates obesity, which is a major risk factor for deep
vein thrombosis (DVT) due to venous stasis and increased intra-abdominal
pressure. BMI 38.6 (A) is correct.
3. A nurse is caring for a client who has neutropenia following cyclosporine
therapy. Which of the following actions should the nurse take?
A. Monitor the client's vital signs every 8 hr
, B. Keep a designated blood pressure cuff in the client's room
C. Inspect the client's mucous membranes daily
D. Avoid the use of alcohol based hand sanitizers prior to client care
Correct Answer: B
Rationale: Clients with neutropenia are at high risk for infection. Keeping
dedicated equipment (e.g., BP cuff) in the room reduces
cross-contamination. Keep a designated blood pressure cuff in the client's room
(B).
4. A nurse is completing a preoperative assessment on a client who is
scheduled for surgery in the morning. Which of the following findings
should indicate to the nurse that the client is at risk for increased bleeding?
A. History of smoking
B. Shellfish allergy
C. Uses St John's wort
D. Takes a garlic supplement
Correct Answer: D
Rationale: Garlic supplements inhibit platelet aggregation and increase bleeding
risk. Takes a garlic supplement (D).
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
Rationale: Calcium 12.3 mg/dL indicates hypercalcemia (normal 9-10.5).
Hypercalcemia causes neurologic depression (lethargy, confusion). Muscle spasms
and Chvostek's sign occur in hypocalcemia. Lethargy (A).
6. A nurse is assessing a client with heart failure who has been taking
furosemide. Which finding indicates the medication is effective?
A. Weight gain of 1 kg in 24 hours
B. Jugular vein distention
C. Decreased shortness of breath
D. Crackles in the lung bases
,Correct Answer: C
Rationale: Effective furosemide therapy reduces fluid overload, leading
to decreased shortness of breath (C). Weight gain, JVD, and crackles indicate
worsening fluid status.
7. A nurse is reinforcing teaching about warfarin with a client who has atrial
fibrillation. Which statement by the client indicates understanding?
A. "I will take ibuprofen for headaches."
B. "I will eat more leafy green vegetables."
C. "I will report any unusual bleeding to my provider."
D. "I will stop taking warfarin if I miss a dose."
Correct Answer: C
Rationale: Clients on warfarin should report any unusual bleeding (C). Avoid
NSAIDs, keep vitamin K intake consistent, and do not stop warfarin without
instruction.
8. A nurse is caring for a client with pneumonia who has a fever of 102°F
(38.9°C). Which intervention should the nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Provide a tepid sponge bath
D. Encourage oral fluids
Correct Answer: B
Rationale: First, remove excess blankets (B) to promote heat loss.
Acetaminophen, fluids, and tepid baths are secondary.
9. A nurse is assessing a client with chronic kidney disease. Which laboratory
finding is most concerning?
A. Hemoglobin 11 g/dL
B. Serum potassium 6.2 mEq/L
C. Serum creatinine 2.5 mg/dL
D. BUN 35 mg/dL
Correct Answer: B
Rationale: Potassium 6.2 mEq/L is dangerously high and can cause cardiac
dysrhythmias. Serum potassium 6.2 mEq/L (B) is most concerning.
10.A nurse is preparing to insert a nasogastric tube. Which position is most
appropriate for the client?
, A. Supine with head flat
B. Semi-Fowler's with head tilted forward
C. Prone
D. Trendelenburg
Correct Answer: B
Rationale: Semi-Fowler's with head tilted forward (B) closes the trachea and
opens the esophagus, facilitating passage.
11.A nurse is caring for a client with a new tracheostomy. Which finding
should be reported immediately?
A. Small amount of blood at the stoma site
B. Crackles auscultated over the trachea
C. Difficulty breathing
D. Moist, pink stoma
Correct Answer: C
Rationale: Difficulty breathing (C) indicates airway obstruction or other
emergency. Small blood and moist stoma are expected; crackles may indicate
secretions but are not immediate.
12.A nurse is reinforcing teaching about testicular self-examination to a young
adult male. Which statement indicates understanding?
A. "I will perform the exam once a year at my checkup."
B. "I will do the exam after a warm shower."
C. "I should squeeze the testicle firmly to feel for lumps."
D. "The best time is in the morning before any activity."
Correct Answer: B
Rationale: Testicular self-examination is best performed after a warm shower
(B) when the scrotal skin is relaxed. It should be done monthly, with gentle rolling.
13.A nurse is assessing a client with a head injury who has clear drainage from
the nose. Which test should the nurse perform to determine if the drainage is
cerebrospinal fluid (CSF)?
A. Check for glucose on a test strip
B. Assess for a halo sign on a gauze pad
C. Measure the pH of the drainage
D. Clamp the nose and observe for swelling
Surgical Assessment 1 & 2 – Complete
Exam (160 Questions)
1. A nurse is educating a group of clients about menopause. Which of the
following information should the nurse include?
A. Limit exercise to 30 min, one to two times a week to reduce fatigue
B. Hormone therapy (HT) is no longer used because of the risk of cancer
C. Vaginal bleeding after 1 year without menses should be reported to the
provider
D. The use of complementary therapies to treat hot flashes should be
avoided
Correct Answer: C
Rationale: Any vaginal bleeding occurring 1 year after menses have stopped
should be reported to the provider because it can indicate a malignant process, not
just menopause. Vaginal bleeding after 1 year without menses should be
reported to the provider (C).
2. A nurse is reviewing the medical record of a client who is to undergo a
surgical procedure. Which of the following findings indicates that the client
is at risk for developing DVT?
A. BMI 38.6
B. History of asthma
C. Use of glucosamine sulfate
D. Hypothyroidism
Correct Answer: A
Rationale: A BMI of 38.6 indicates obesity, which is a major risk factor for deep
vein thrombosis (DVT) due to venous stasis and increased intra-abdominal
pressure. BMI 38.6 (A) is correct.
3. A nurse is caring for a client who has neutropenia following cyclosporine
therapy. Which of the following actions should the nurse take?
A. Monitor the client's vital signs every 8 hr
, B. Keep a designated blood pressure cuff in the client's room
C. Inspect the client's mucous membranes daily
D. Avoid the use of alcohol based hand sanitizers prior to client care
Correct Answer: B
Rationale: Clients with neutropenia are at high risk for infection. Keeping
dedicated equipment (e.g., BP cuff) in the room reduces
cross-contamination. Keep a designated blood pressure cuff in the client's room
(B).
4. A nurse is completing a preoperative assessment on a client who is
scheduled for surgery in the morning. Which of the following findings
should indicate to the nurse that the client is at risk for increased bleeding?
A. History of smoking
B. Shellfish allergy
C. Uses St John's wort
D. Takes a garlic supplement
Correct Answer: D
Rationale: Garlic supplements inhibit platelet aggregation and increase bleeding
risk. Takes a garlic supplement (D).
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
Rationale: Calcium 12.3 mg/dL indicates hypercalcemia (normal 9-10.5).
Hypercalcemia causes neurologic depression (lethargy, confusion). Muscle spasms
and Chvostek's sign occur in hypocalcemia. Lethargy (A).
6. A nurse is assessing a client with heart failure who has been taking
furosemide. Which finding indicates the medication is effective?
A. Weight gain of 1 kg in 24 hours
B. Jugular vein distention
C. Decreased shortness of breath
D. Crackles in the lung bases
,Correct Answer: C
Rationale: Effective furosemide therapy reduces fluid overload, leading
to decreased shortness of breath (C). Weight gain, JVD, and crackles indicate
worsening fluid status.
7. A nurse is reinforcing teaching about warfarin with a client who has atrial
fibrillation. Which statement by the client indicates understanding?
A. "I will take ibuprofen for headaches."
B. "I will eat more leafy green vegetables."
C. "I will report any unusual bleeding to my provider."
D. "I will stop taking warfarin if I miss a dose."
Correct Answer: C
Rationale: Clients on warfarin should report any unusual bleeding (C). Avoid
NSAIDs, keep vitamin K intake consistent, and do not stop warfarin without
instruction.
8. A nurse is caring for a client with pneumonia who has a fever of 102°F
(38.9°C). Which intervention should the nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Provide a tepid sponge bath
D. Encourage oral fluids
Correct Answer: B
Rationale: First, remove excess blankets (B) to promote heat loss.
Acetaminophen, fluids, and tepid baths are secondary.
9. A nurse is assessing a client with chronic kidney disease. Which laboratory
finding is most concerning?
A. Hemoglobin 11 g/dL
B. Serum potassium 6.2 mEq/L
C. Serum creatinine 2.5 mg/dL
D. BUN 35 mg/dL
Correct Answer: B
Rationale: Potassium 6.2 mEq/L is dangerously high and can cause cardiac
dysrhythmias. Serum potassium 6.2 mEq/L (B) is most concerning.
10.A nurse is preparing to insert a nasogastric tube. Which position is most
appropriate for the client?
, A. Supine with head flat
B. Semi-Fowler's with head tilted forward
C. Prone
D. Trendelenburg
Correct Answer: B
Rationale: Semi-Fowler's with head tilted forward (B) closes the trachea and
opens the esophagus, facilitating passage.
11.A nurse is caring for a client with a new tracheostomy. Which finding
should be reported immediately?
A. Small amount of blood at the stoma site
B. Crackles auscultated over the trachea
C. Difficulty breathing
D. Moist, pink stoma
Correct Answer: C
Rationale: Difficulty breathing (C) indicates airway obstruction or other
emergency. Small blood and moist stoma are expected; crackles may indicate
secretions but are not immediate.
12.A nurse is reinforcing teaching about testicular self-examination to a young
adult male. Which statement indicates understanding?
A. "I will perform the exam once a year at my checkup."
B. "I will do the exam after a warm shower."
C. "I should squeeze the testicle firmly to feel for lumps."
D. "The best time is in the morning before any activity."
Correct Answer: B
Rationale: Testicular self-examination is best performed after a warm shower
(B) when the scrotal skin is relaxed. It should be done monthly, with gentle rolling.
13.A nurse is assessing a client with a head injury who has clear drainage from
the nose. Which test should the nurse perform to determine if the drainage is
cerebrospinal fluid (CSF)?
A. Check for glucose on a test strip
B. Assess for a halo sign on a gauze pad
C. Measure the pH of the drainage
D. Clamp the nose and observe for swelling
