CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
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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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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
,CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
DOWNLOAD 2024/2025 BEST EXAM SOLUTION GRADED A+
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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 - CORRECT ANSWERS C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the
following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - CORRECT ANSWERS A, D, E
A, complete assessment prior to transfusion
D, verify identification, blood compatibility, and expiration of product with second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell
hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following
BUN levels should the nurse expect
, CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
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A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - CORRECT ANSWERS D 26 mg/dL
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive
protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is
reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse
identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than
the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - CORRECT ANSWERS A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which
of the following items is the priority for the nurse to have available in the client's room upon
admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
DOWNLOAD 2024/2025 BEST EXAM SOLUTION GRADED A+
FOR SUCCESS
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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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
,CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
DOWNLOAD 2024/2025 BEST EXAM SOLUTION GRADED A+
FOR SUCCESS
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 - CORRECT ANSWERS C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the
following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - CORRECT ANSWERS A, D, E
A, complete assessment prior to transfusion
D, verify identification, blood compatibility, and expiration of product with second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell
hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following
BUN levels should the nurse expect
, CAPSTONE ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
QUESTIONS AND CORRECT DETAILED ANSWERS LATEST
DOWNLOAD 2024/2025 BEST EXAM SOLUTION GRADED A+
FOR SUCCESS
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - CORRECT ANSWERS D 26 mg/dL
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive
protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is
reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse
identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than
the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - CORRECT ANSWERS A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which
of the following items is the priority for the nurse to have available in the client's room upon
admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
