MED SURG ATI CAPSTONE, ATI NCLEX
MEDICAL SURGICAL ASSESSMENT 1,
MED SURG 2. EXAM QUESTIONS AND
ANSWERS 100% PASS.
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 - ANS 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 - ANS B, C, E
2026 STUDY MATERIAL @COPYRIGHT RESERVED 1
,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 - ANS 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 - ANS 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 - ANS 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)
2026 STUDY MATERIAL @COPYRIGHT RESERVED 2
,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 - ANS 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 - ANS 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 - ANS 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"
2026 STUDY MATERIAL @COPYRIGHT RESERVED 3
, B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" - ANS 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" - ANS 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 - ANS 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)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
2026 STUDY MATERIAL @COPYRIGHT RESERVED 4
MEDICAL SURGICAL ASSESSMENT 1,
MED SURG 2. EXAM QUESTIONS AND
ANSWERS 100% PASS.
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 - ANS 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 - ANS B, C, E
2026 STUDY MATERIAL @COPYRIGHT RESERVED 1
,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 - ANS 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 - ANS 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 - ANS 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)
2026 STUDY MATERIAL @COPYRIGHT RESERVED 2
,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 - ANS 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 - ANS 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 - ANS 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"
2026 STUDY MATERIAL @COPYRIGHT RESERVED 3
, B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" - ANS 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" - ANS 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 - ANS 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)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
2026 STUDY MATERIAL @COPYRIGHT RESERVED 4
