ATI CAPSTONE MEDICAL SURGICAL
ASSESSMENT 1 & 2 ACTUAL REAL EXAM
QUESTIONS AND ANSWERS | VERIFIED
AND ACCURATE | GRADED A
Capstone ATI NCLEX Medical Surgical Assessment 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
• "Wait at least 5 minutes between puffs from the same inhaler"
• "Breathe in rapidly when inhaling the medication"
• "Clean the plastic inhaler cap weekly with cold water"
• "Shake the inhaler vigorously prior to use" - ANSWER-D .) "Shake the
inhaler vigorously prior to use"
Thoroughly shake the inhaler to disperse the medication because the medication
in the inhaler can separate easily
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
• Provide the client with a means of communication
• Maintain the head of the client's bed in a flat position
• Suction the client's endotracheal tube every 4 hr
• Perform oral hygiene for the client every 8 hr - ANSWER-A.) Provide the
client with a means of communication
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
• Sodium 165 mEq/L
• Potassium 5.2 mEq/L
• Urine specific gravity 1.020
• Hct 62% - ANSWER-C Urine specific gravity 1.020 Within the expected
range of 1.005-1.030
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
• PT 11.5 seconds
• aPTT 35 seconds
• Platelets 80,000
• RBC 4.0 million - ANSWER-C Platelets 80,000 platelet range is 150,000-
400,000
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
• Change the client's position every 2 hours
• Pad pressure points at the edges of the client's cervical collar
• Palpate the client's abdomen for bladder distention
,• Assist the client with quad coughing - ANSWER-D Assist the client with
quad coughing
The greatest risk to a client who has a cervical spinal cord injury is an obstructed
airway; the priority is to ensure the client can clear their airway. Apply abdominal
pressure as the client coughs (quad coughing)
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
• Nasuea
• Hypothermia
• Dyspnea
• Bradycardia - ANSWER-C Dyspnea
Dyspnea is an indication of possible transfusion associated circulatory overload,
leading to hypertension, bounding pulses, and confusion. Dyspnea can also
indicate transfusion related acute lung injury to an anaphylactic response, which
also causes wheezing, chest tightness, cyanosis, and low BP
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
• Hair loss on the scalp
• Sweating at the treatment site
• Altered taste sensations
• Intolerance to cold - ANSWER-C Altered taste sensations Altered taste is a
result of the release of metabolites by dead cells
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)
, • Obtain pre-transfusion temperature
• Prime the IV tubing with lactated Ringer's
• Instruct an assistive personnel to monitor the client during the transfusion
• Verify the client's blood type with a second nurse
• 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 reviewing the laboratory findings for a client who is dehydrated. Which
of the following BUN levels should the nurse expect
Normal range is 10-20, and elevated levels indicates renal disease, dehydration,
shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or
other conditions in which blood is reabsorbed from injured tissues
A nurse is monitoring a client who is receiving moderate sedation with
midazolam. Which of the following findings requires immediate intervention by
the nurse
• Oxygen saturation 90%
• No response to verbal stimuli
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