Capstone ATI NCLEX Medical Surgical Assessment 1
1. 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" Ans: D .) "Shake the inhaler vigorously
prior to use"
Thoroughly shake the inhaler to disperse the medication because the medication in the inhal
can separate easily
2. 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 Ans: A.) Provide the client with a
means of communication
Use electronic tablet computer, programmable speech generating device, alphabet board,
pencil and paper, etc
3. A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effective- ness of the
treatment
,A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% Ans: C Urine specific gravity
1.020 Within the expected range of 1.005-
1.030
4. A nurse is monitoring the laboratory findings for a client who is postoper- ative
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 Ans: C Platelets
80,000 platelet range is 150,000-400,000
,5. 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 Ans: 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)
6. 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-as- sociated
circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia Ans: 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
7. 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 Ans: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
8. 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
1. 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" Ans: D .) "Shake the inhaler vigorously
prior to use"
Thoroughly shake the inhaler to disperse the medication because the medication in the inhal
can separate easily
2. 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 Ans: A.) Provide the client with a
means of communication
Use electronic tablet computer, programmable speech generating device, alphabet board,
pencil and paper, etc
3. A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effective- ness of the
treatment
,A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% Ans: C Urine specific gravity
1.020 Within the expected range of 1.005-
1.030
4. A nurse is monitoring the laboratory findings for a client who is postoper- ative
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 Ans: C Platelets
80,000 platelet range is 150,000-400,000
,5. 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 Ans: 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)
6. 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-as- sociated
circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia Ans: 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
7. 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 Ans: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
8. 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
