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CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1
[LATEST UPDATED VERSION]
PROVIDING ACTUAL EXAMS TIPS SAT ON 2025
A nurse is providing teaching to a client who is undergoing radiation therapy
and wants to go for a walk outside. Which of the following recommendations
should the nurse include in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go outdoors"
B. "Gently was the irradiated area to remove the markings before going
outside"
C. "Protect exposed skin with an over the counter sunscreen"
D. "Wear form sitting clothing when going outside" - ANS A) "Try to avoid sun
exposure by waiting until after sunset to go outdoors"
Protect the skin from exposure to sunlight during treatment and for 1 year
after the last treatment. Stay in the shade, go outside in the early morning or
evening to avoid the more intense sun rays to allow the pt to stay outside for a
longer period
A nurse in an emergency department is monitoring a client who reports angina.
Which of the following findings should indicate to the nurse that the client
might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - ANS A ) Increased troponin
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Troponin is a myocardial muscle protein released into the blood stream as a
result of injury to the heart muscle. Troponin levels increase within 2-3 hr
following an MI
A nurse is preparing to obtain blood cultures from a client's central venous
catheter (CVC). Which of the following actions should the nurse take when
accessing the catheter
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen - ANS
B) Aspirate for blood return prior to each use
A nurse on a medical surgical unit has received shift report for a group of
clients. Which of the following interventions should the nurse plan to complete
first
A. Perform a dressing change on a client who is 24 hr postoperative following
abdominal surgery and has sanguineous drainage on the dressing
B. Replace an infiltrated IV for a client who has pneumonia and has scheduled
IV antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is reporting
back pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min - ANS D) Assess a client who is 4hr postoperative
following thoracic surgery and has a respiratory rate of 7/min
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Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation
and can indicate respiratory failure or shock, especially in pt who is postop.
A nurse on a medical unit is planning care for a client who has COPD. Which of
the following actions should the nurse include in the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal - ANS C) Provide
the client with a high protein diet
COPD needs a diet high in protein and calories. They should eat freuqent, small
meals and should avoid drinking fluids prior to or during meals
A nurse is administering parenteral nutrition to a client who has a history of
heart failure. Which of the following manifestations indicates to the nurse that
the client is experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss - ANS C
when the client is recumbent, the extracellular fluid enters the vascular system
and increases the blood volume filtering through the kidneys, which increases
urine production
--
A, hypertension indicates fluid overload in a pt with heart failure
CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1
[LATEST UPDATED VERSION]
PROVIDING ACTUAL EXAMS TIPS SAT ON 2025
A nurse is providing teaching to a client who is undergoing radiation therapy
and wants to go for a walk outside. Which of the following recommendations
should the nurse include in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go outdoors"
B. "Gently was the irradiated area to remove the markings before going
outside"
C. "Protect exposed skin with an over the counter sunscreen"
D. "Wear form sitting clothing when going outside" - ANS A) "Try to avoid sun
exposure by waiting until after sunset to go outdoors"
Protect the skin from exposure to sunlight during treatment and for 1 year
after the last treatment. Stay in the shade, go outside in the early morning or
evening to avoid the more intense sun rays to allow the pt to stay outside for a
longer period
A nurse in an emergency department is monitoring a client who reports angina.
Which of the following findings should indicate to the nurse that the client
might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - ANS A ) Increased troponin
,2|Page
Troponin is a myocardial muscle protein released into the blood stream as a
result of injury to the heart muscle. Troponin levels increase within 2-3 hr
following an MI
A nurse is preparing to obtain blood cultures from a client's central venous
catheter (CVC). Which of the following actions should the nurse take when
accessing the catheter
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen - ANS
B) Aspirate for blood return prior to each use
A nurse on a medical surgical unit has received shift report for a group of
clients. Which of the following interventions should the nurse plan to complete
first
A. Perform a dressing change on a client who is 24 hr postoperative following
abdominal surgery and has sanguineous drainage on the dressing
B. Replace an infiltrated IV for a client who has pneumonia and has scheduled
IV antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is reporting
back pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min - ANS D) Assess a client who is 4hr postoperative
following thoracic surgery and has a respiratory rate of 7/min
, 3|Page
Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation
and can indicate respiratory failure or shock, especially in pt who is postop.
A nurse on a medical unit is planning care for a client who has COPD. Which of
the following actions should the nurse include in the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal - ANS C) Provide
the client with a high protein diet
COPD needs a diet high in protein and calories. They should eat freuqent, small
meals and should avoid drinking fluids prior to or during meals
A nurse is administering parenteral nutrition to a client who has a history of
heart failure. Which of the following manifestations indicates to the nurse that
the client is experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss - ANS C
when the client is recumbent, the extracellular fluid enters the vascular system
and increases the blood volume filtering through the kidneys, which increases
urine production
--
A, hypertension indicates fluid overload in a pt with heart failure
