ATI Capstone Medical Surgical assessment NCLEX Exam
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with 43 Questions and Verified Answers
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Graded A+ 2024/2025 n n
1. A nurse on a med surg unit iscaring for a group of clients.The nurse should notify thera
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pid response team for which of the following clients?
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A. Client who has an ulceration of the right heel whose blood glucose is 300
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B. Client who reports right calf pain and shortness of breath
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C. Client who has blood on a pressure dressing in the femoral area following a cardiacca
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theterization
D. Client who has dark red coloration of left toes and absent pedal pulse: B
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2. A nurse is caring for a client who has ingested a toxic agent.Which of the followingac
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tions should the nurse plan to take? (Select all that apply)
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A. Induce vomiting n
B. Instill activated charcoal
n n
C. Perform a gastric lavage with aspiration
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D. Administer syrup of ipecac n n n
E. Infuse IV fluids: B, C, E
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3. A nurse in the emergency department is caring for a client who fell through the ice ona
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pond and is unresponsive and breathing slowly. Which of the following actions
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1n/n19
,should the nurse take? (Select all that apply)
n n n n n n n
A. Remove wet clothing n n
B. Maintain normal room temperature n n n
C. Apply warm blanketsn n
D. Apply a heat lamp n n n
E. Infuse warmed IV fluids: A, C, D, E
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4. A nurse in the ED is assessing a client who is unresponsive. The client's partner st
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ates,"Hewaspulling weedsin the yard and slumped to the ground." Which of the foll
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owing techniques should the nurse use to open the client's airway?
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A. Head-tilt, chin-lift n
B. Modified jaw thrust n n
C. Hyperextension of the head n n n
D. Flexion of the head: A n n n n
5. A nurse is reviewing the common emergency management protocol for clientsw
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ho have asystole.Which of the following actions should the nurse plan to take duri
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ng this cardiac emergency?
n n n
A. Perform defibrillation n
2n/n19
, B. Prepare for transcutaneous pacing n n n
C. Administer IV epinephrine n n
D. Elevate the client's lower extremities: C
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6. A nurse is caring for a client who is postprocedural following LP and re-
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n ports throbbing headache when sitting upright.Which of the following actions shoul
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d thenurse take? (Select all that apply)
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A. Use the Glasgow Coma Scale when assessing the client
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B. Assist the client to a supine position
n n n n n n
C. Administer an opioid medication n n n
D. Encourage the client to increase fluid intake n n n n n n
E. Instruct the client to perform deep breathing exercises and coughing exer-
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n cises: B,C, D n n n
7. A nurse is caring for a client who experienced a traumatic head injury and has anin
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traventricular catheter (ventriculostomy) for ICP monitoring. n n n n n
The nurse should monitor the client for which of the following complications related tot
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he ventriculostomy?
n
A. Headache
B. Infection
C. Aphasia
D. Hypertension: B n
8. A nurse is assessing a client for changes in the level of consciousness usingtheG
n n n n n n n n n n n n n n
CS.The client opens his eyes when spokento,speaksincoherently, and moves his
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extremities when pain is applied. Which of the following GCS scores should the nurse
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3n/n19
n n n n n n n
with 43 Questions and Verified Answers
n n n n n
Graded A+ 2024/2025 n n
1. A nurse on a med surg unit iscaring for a group of clients.The nurse should notify thera
n n n n n n n n n n n n n n n n n
pid response team for which of the following clients?
n n n n n n n n
A. Client who has an ulceration of the right heel whose blood glucose is 300
n n n n n n n n n n n n n
B. Client who reports right calf pain and shortness of breath
n n n n n n n n n
C. Client who has blood on a pressure dressing in the femoral area following a cardiacca
n n n n n n n n n n n n n n n
theterization
D. Client who has dark red coloration of left toes and absent pedal pulse: B
n n n n n n n n n n n n n
2. A nurse is caring for a client who has ingested a toxic agent.Which of the followingac
n n n n n n n n n n n n n n n n
tions should the nurse plan to take? (Select all that apply)
n n n n n n n n n n
A. Induce vomiting n
B. Instill activated charcoal
n n
C. Perform a gastric lavage with aspiration
n n n n n
D. Administer syrup of ipecac n n n
E. Infuse IV fluids: B, C, E
n n n n n
3. A nurse in the emergency department is caring for a client who fell through the ice ona
n n n n n n n n n n n n n n n n n n
pond and is unresponsive and breathing slowly. Which of the following actions
n n n n n n n n n n n
1n/n19
,should the nurse take? (Select all that apply)
n n n n n n n
A. Remove wet clothing n n
B. Maintain normal room temperature n n n
C. Apply warm blanketsn n
D. Apply a heat lamp n n n
E. Infuse warmed IV fluids: A, C, D, E
n n n n n n n
4. A nurse in the ED is assessing a client who is unresponsive. The client's partner st
n n n n n n n n n n n n n n n
ates,"Hewaspulling weedsin the yard and slumped to the ground." Which of the foll
n n n n n n n n n n n n
owing techniques should the nurse use to open the client's airway?
n n n n n n n n n n
A. Head-tilt, chin-lift n
B. Modified jaw thrust n n
C. Hyperextension of the head n n n
D. Flexion of the head: A n n n n
5. A nurse is reviewing the common emergency management protocol for clientsw
n n n n n n n n n n n
ho have asystole.Which of the following actions should the nurse plan to take duri
n n n n n n n n n n n n n
ng this cardiac emergency?
n n n
A. Perform defibrillation n
2n/n19
, B. Prepare for transcutaneous pacing n n n
C. Administer IV epinephrine n n
D. Elevate the client's lower extremities: C
n n n n n
6. A nurse is caring for a client who is postprocedural following LP and re-
n n n n n n n n n n n n n
n ports throbbing headache when sitting upright.Which of the following actions shoul
n n n n n n n n n n
d thenurse take? (Select all that apply)
n n n n n n n
A. Use the Glasgow Coma Scale when assessing the client
n n n n n n n n
B. Assist the client to a supine position
n n n n n n
C. Administer an opioid medication n n n
D. Encourage the client to increase fluid intake n n n n n n
E. Instruct the client to perform deep breathing exercises and coughing exer-
n n n n n n n n n n
n cises: B,C, D n n n
7. A nurse is caring for a client who experienced a traumatic head injury and has anin
n n n n n n n n n n n n n n n n
traventricular catheter (ventriculostomy) for ICP monitoring. n n n n n
The nurse should monitor the client for which of the following complications related tot
n n n n n n n n n n n n n n
he ventriculostomy?
n
A. Headache
B. Infection
C. Aphasia
D. Hypertension: B n
8. A nurse is assessing a client for changes in the level of consciousness usingtheG
n n n n n n n n n n n n n n
CS.The client opens his eyes when spokento,speaksincoherently, and moves his
n n n n n n n n n
extremities when pain is applied. Which of the following GCS scores should the nurse
n n n n n n n n n n n n n
3n/n19
