Capstone ATI NCLEX Medical Surgical
Assessment Questions and Detailed
Verified Answers 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" -Answer:-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 -Answer:-A ) Increased troponin
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 -Answer:-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 -Answer:-D) Assess a
client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min
, 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 -
Answer:-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
Assessment Questions and Detailed
Verified Answers 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" -Answer:-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 -Answer:-A ) Increased troponin
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 -Answer:-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 -Answer:-D) Assess a
client who is 4hr postoperative following thoracic surgery and has a
respiratory rate of 7/min
, 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 -
Answer:-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
