ATI CAPSTONE MEDICAL SURGICAL ASSESSMENT 1 & 2 ALL 150
QUESTIONS AND CORRECT WELL ELABORATED ANSWERS
WITH RATIONALES
Question 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."
E) "Exhale forcefully after inhaling the medication."
Correct Answer: D) "Shake the inhaler vigorously prior to use"
Rationale: Thoroughly shaking the inhaler is crucial to disperse the medication
evenly because the medication in the inhaler can settle and separate easily,
ensuring the correct dose is delivered.
Question 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 to promote client well-being?
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.
E) Restrict visitors to minimize stimulation.
,Correct Answer: A) Provide the client with a means of communication.
Rationale: Clients on mechanical ventilation are often unable to speak. Providing
alternative communication methods (e.g., electronic tablet, alphabet board, pen
and paper) is crucial to reduce frustration, anxiety, and enable them to express
needs.
Question 3
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration.
Which of the following laboratory results indicates effectiveness of the treatment?
A) Sodium 165 mEq/L.
B) Potassium 5.2 mEq/L.
C) Urine specific gravity 1.020.
D) Hct 62%.
E) BUN 28 mg/dL.
Correct Answer: C) Urine specific gravity 1.020.
Rationale: A urine specific gravity within the expected range of 1.005-1.030 (e.g.,
1.020) indicates adequate hydration. Dehydration typically causes an increased
urine specific gravity. The other options indicate hypernatremia, hyperkalemia, or
hemoconcentration (suggesting ongoing dehydration).
Question 4
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/mm3.
D) RBC 4.0 million/uL.
E) INR 1.0.
Correct Answer: C) Platelets 80,000.
Rationale: The normal platelet range is 150,000-400,000/mm3. A platelet count of
80,000/mm3 is significantly below normal (thrombocytopenia) and indicates an
increased risk for bleeding, which is a critical concern postoperative.
Question 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.
E) Assess for deep vein thrombosis.
Correct Answer: D) Assist the client with quad coughing.
Rationale: The greatest risk to a client who has a cervical spinal cord injury is an
obstructed airway due to ineffective coughing and secretion clearance. The priority
is to ensure the client can clear their airway by assisting with quad coughing
(applying abdominal pressure as the client attempts to cough).
, Question 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-associated circulatory overload
(TACO)?
A) Nausea.
B) Hypothermia.
C) Dyspnea.
D) Bradycardia.
E) Urticaria.
Correct Answer: C) Dyspnea.
Rationale: Dyspnea is a primary indication of possible transfusion-associated
circulatory overload, which occurs when blood is transfused too rapidly. Other
signs include hypertension, bounding pulses, crackles, and confusion.
Question 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.
E) Increased appetite.
QUESTIONS AND CORRECT WELL ELABORATED ANSWERS
WITH RATIONALES
Question 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."
E) "Exhale forcefully after inhaling the medication."
Correct Answer: D) "Shake the inhaler vigorously prior to use"
Rationale: Thoroughly shaking the inhaler is crucial to disperse the medication
evenly because the medication in the inhaler can settle and separate easily,
ensuring the correct dose is delivered.
Question 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 to promote client well-being?
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.
E) Restrict visitors to minimize stimulation.
,Correct Answer: A) Provide the client with a means of communication.
Rationale: Clients on mechanical ventilation are often unable to speak. Providing
alternative communication methods (e.g., electronic tablet, alphabet board, pen
and paper) is crucial to reduce frustration, anxiety, and enable them to express
needs.
Question 3
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration.
Which of the following laboratory results indicates effectiveness of the treatment?
A) Sodium 165 mEq/L.
B) Potassium 5.2 mEq/L.
C) Urine specific gravity 1.020.
D) Hct 62%.
E) BUN 28 mg/dL.
Correct Answer: C) Urine specific gravity 1.020.
Rationale: A urine specific gravity within the expected range of 1.005-1.030 (e.g.,
1.020) indicates adequate hydration. Dehydration typically causes an increased
urine specific gravity. The other options indicate hypernatremia, hyperkalemia, or
hemoconcentration (suggesting ongoing dehydration).
Question 4
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/mm3.
D) RBC 4.0 million/uL.
E) INR 1.0.
Correct Answer: C) Platelets 80,000.
Rationale: The normal platelet range is 150,000-400,000/mm3. A platelet count of
80,000/mm3 is significantly below normal (thrombocytopenia) and indicates an
increased risk for bleeding, which is a critical concern postoperative.
Question 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.
E) Assess for deep vein thrombosis.
Correct Answer: D) Assist the client with quad coughing.
Rationale: The greatest risk to a client who has a cervical spinal cord injury is an
obstructed airway due to ineffective coughing and secretion clearance. The priority
is to ensure the client can clear their airway by assisting with quad coughing
(applying abdominal pressure as the client attempts to cough).
, Question 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-associated circulatory overload
(TACO)?
A) Nausea.
B) Hypothermia.
C) Dyspnea.
D) Bradycardia.
E) Urticaria.
Correct Answer: C) Dyspnea.
Rationale: Dyspnea is a primary indication of possible transfusion-associated
circulatory overload, which occurs when blood is transfused too rapidly. Other
signs include hypertension, bounding pulses, crackles, and confusion.
Question 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.
E) Increased appetite.
