NEW CAPSTONE ATI NCLEX MEDICAL SURGICAL
ASSESSMENT 1 WITH Q&A TESTED AND
APPROVED!!!
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 -- ANSWER--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 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
Page 1 of 91
,C. Sterile gloves
D. Inner cannula -- ANSWER--A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or decannulation to
maintain an airway until a new trach tube can be placed. For the first 72 hr following the
insertion of a trach, dislodgement or decannulation is considered an emergency
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury
2 days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to make when doing your job"
C. "Let's discuss how you can adjust once you have a prosthesis"
D. "What are some possible issues that you foresee when completing self-management
tasks" -- ANSWER--A .) "Tell me how the changes to your leg make you feel"
A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a
colonoscopy for colon cancer screening. Which of the following information should the nurse
provide
A. "You should have nothing to eat or drink for 3 hours prior to the procedure"
B. "You should drink the bowel preparation slowly to prevent nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure" -- ANSWER--D.)
"You will need someone to drive you home after your procedure"
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,Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt
receives moderate sedation
A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of
the following findings requires immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs) D. Nausea -- ANSWER--B)
No response to verbal stimuli using urgent vs non-urgent approach, this is the priority. During
moderate sedation, the pt should be able to provide a response to questions and commands.
No response to verbal stimuli can indicate a loss or consciousness or oversedation
A nurse is reviewing the laboratory findings for a client who has heart failure and is taking
furosemide. The nurse should identify which of the following findings as an adverse effect of
the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia -- ANSWER--C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased
excretion of potassium. Monitor for dysrhythmias
A nurse is caring for a client who is in Buck's traction. Which of the following actions should
the nurse take? (select all that apply)
Page 3 of 91
, A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction bood
E. Assess the temperature of the affected extremity -- ANSWER--A, D, E
--
A, closely monitor the neurovascular integrity. Circulation can be compromised from the
fracture as well as the traction device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well as the traction device. Check
and document color, temperature, distal pulses, capillary refill, movement, and sensation
during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure,
paresthesia, and paralysis
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 -- ANSWER--A.) Provide the client
with a means of communication
Use electronic tablet computer, programmable speech generating device, alphabet board,
pencil and paper, etc
Page 4 of 91
ASSESSMENT 1 WITH Q&A TESTED AND
APPROVED!!!
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 -- ANSWER--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 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
Page 1 of 91
,C. Sterile gloves
D. Inner cannula -- ANSWER--A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or decannulation to
maintain an airway until a new trach tube can be placed. For the first 72 hr following the
insertion of a trach, dislodgement or decannulation is considered an emergency
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury
2 days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to make when doing your job"
C. "Let's discuss how you can adjust once you have a prosthesis"
D. "What are some possible issues that you foresee when completing self-management
tasks" -- ANSWER--A .) "Tell me how the changes to your leg make you feel"
A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a
colonoscopy for colon cancer screening. Which of the following information should the nurse
provide
A. "You should have nothing to eat or drink for 3 hours prior to the procedure"
B. "You should drink the bowel preparation slowly to prevent nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure" -- ANSWER--D.)
"You will need someone to drive you home after your procedure"
Page 2 of 91
,Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt
receives moderate sedation
A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of
the following findings requires immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs) D. Nausea -- ANSWER--B)
No response to verbal stimuli using urgent vs non-urgent approach, this is the priority. During
moderate sedation, the pt should be able to provide a response to questions and commands.
No response to verbal stimuli can indicate a loss or consciousness or oversedation
A nurse is reviewing the laboratory findings for a client who has heart failure and is taking
furosemide. The nurse should identify which of the following findings as an adverse effect of
the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia -- ANSWER--C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased
excretion of potassium. Monitor for dysrhythmias
A nurse is caring for a client who is in Buck's traction. Which of the following actions should
the nurse take? (select all that apply)
Page 3 of 91
, A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction bood
E. Assess the temperature of the affected extremity -- ANSWER--A, D, E
--
A, closely monitor the neurovascular integrity. Circulation can be compromised from the
fracture as well as the traction device
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well as the traction device. Check
and document color, temperature, distal pulses, capillary refill, movement, and sensation
during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure,
paresthesia, and paralysis
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 -- ANSWER--A.) Provide the client
with a means of communication
Use electronic tablet computer, programmable speech generating device, alphabet board,
pencil and paper, etc
Page 4 of 91
