MED SURG ATI CAPSTONE | ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1 &
MED SURG 2 – ACTUAL EXAM QUESTIONS & CORRECT ANSWERS (2024/2025)
A nurse on a med surg unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse -
E. Answer--B
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids -
F. Answer--B, C, E
A nurse in the emergency department is caring for a client who fell through the
ice on a pond and is unresponsive and breathing slowly. Which of the following
actions should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids -
F. Answer--A, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of
the following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head -
E. Answer--A
A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
,C. Administer IV epinephrine
D. Elevate the client's lower extremities -
E. Answer--C
A nurse is caring for a client who is postprocedural following LP and reports
throbbing headache when sitting upright. Which of the following actions should
the nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises -
F. Answer--B, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should
monitor the client for which of the following complications related to the
ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension -
E. Answer--B
A nurse is assessing a client for changes in the level of consciousness using the
GCS. The client opens his eyes when spoken to, speaks incoherently, and moves
his extremities when pain is applied. Which of the following GCS scores should
the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 -
E. Answer--B
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply)
A. "I think I might be pregnant"
B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" -
F. Answer--A, B, D, E
A nurse is providing education to a client who is to undergo an EEG the next day.
Which of the following information should the nurse include in the teaching?
,A. "Do not wash your hair the morning of the procedure"
B. "Try to stay awake most of the night prior to the procedure"
C. "The procedure will take approximately 15 minutes"
D. "You will need to lie flat for 4 hours after the procedure" -
E. Answer--B
A nurse is assessing a client who reports severe headache and a stiff neck. The
nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of
the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights -
E. Answer--B
A nurse is assessing for the presence of Brudzinski's sign in a client who has
suspected meningitis. Which of the following actions should the nurse take when
performing this technique? (Select all that apply)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
E. Straighten the client's flexed leg at the knee -
F. Answer--A, C, D
A nurse is planning care for a client who has meningitis and is at risk for
increased ICP. Which of the following actions should the nurse plan to take?
(Select all that apply)
A. Implement seizure precautions
B. Perform neurological checks 4x a day
C. Administer morphine for the report of neck and generalized pain
D. Turn off room lights and television
E. Monitor for impaired extraocular movements
F. Encourage the client to cough frequently -
G. Answer--A, D, E
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the
prevention of meningitis with a newly licensed nurse. Which of the following
information should the nurse include?
A. The vaccine is indicated to reduce the risk of respiratory infection
B. The vaccine is administered in a series of four doses
C. The vaccine is recommended for adolescents before starting college
D. The vaccine is initially given at 2 months of age -
E. Answer--C
A nurse is planning care for a client who has bacterial meningitis. Which of the
following actions should the nurse include in the plan of care? (Select all that
, apply)
MED SURG 2 – ACTUAL EXAM QUESTIONS & CORRECT ANSWERS (2024/2025)
A nurse on a med surg unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse -
E. Answer--B
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Infuse IV fluids -
F. Answer--B, C, E
A nurse in the emergency department is caring for a client who fell through the
ice on a pond and is unresponsive and breathing slowly. Which of the following
actions should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids -
F. Answer--A, C, D, E
A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of
the following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head -
E. Answer--A
A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
,C. Administer IV epinephrine
D. Elevate the client's lower extremities -
E. Answer--C
A nurse is caring for a client who is postprocedural following LP and reports
throbbing headache when sitting upright. Which of the following actions should
the nurse take? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist the client to a supine position
C. Administer an opioid medication
D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises -
F. Answer--B, C, D
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should
monitor the client for which of the following complications related to the
ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension -
E. Answer--B
A nurse is assessing a client for changes in the level of consciousness using the
GCS. The client opens his eyes when spoken to, speaks incoherently, and moves
his extremities when pain is applied. Which of the following GCS scores should
the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 -
E. Answer--B
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply)
A. "I think I might be pregnant"
B. "I take warfarin"
C. "I take antihypertensive medication"
D. "I am allergic to shrimp"
E. "I ate a light breakfast this morning" -
F. Answer--A, B, D, E
A nurse is providing education to a client who is to undergo an EEG the next day.
Which of the following information should the nurse include in the teaching?
,A. "Do not wash your hair the morning of the procedure"
B. "Try to stay awake most of the night prior to the procedure"
C. "The procedure will take approximately 15 minutes"
D. "You will need to lie flat for 4 hours after the procedure" -
E. Answer--B
A nurse is assessing a client who reports severe headache and a stiff neck. The
nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of
the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights -
E. Answer--B
A nurse is assessing for the presence of Brudzinski's sign in a client who has
suspected meningitis. Which of the following actions should the nurse take when
performing this technique? (Select all that apply)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
E. Straighten the client's flexed leg at the knee -
F. Answer--A, C, D
A nurse is planning care for a client who has meningitis and is at risk for
increased ICP. Which of the following actions should the nurse plan to take?
(Select all that apply)
A. Implement seizure precautions
B. Perform neurological checks 4x a day
C. Administer morphine for the report of neck and generalized pain
D. Turn off room lights and television
E. Monitor for impaired extraocular movements
F. Encourage the client to cough frequently -
G. Answer--A, D, E
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the
prevention of meningitis with a newly licensed nurse. Which of the following
information should the nurse include?
A. The vaccine is indicated to reduce the risk of respiratory infection
B. The vaccine is administered in a series of four doses
C. The vaccine is recommended for adolescents before starting college
D. The vaccine is initially given at 2 months of age -
E. Answer--C
A nurse is planning care for a client who has bacterial meningitis. Which of the
following actions should the nurse include in the plan of care? (Select all that
, apply)
