ATI CAPSTONE MEDICAL SURGICAL ASSESSMENT 1 & 2
ALL QUESTIONS AND CORRECT WELL ELABORATED
ANSWERS WITH RATIONALES
1. A nurse is reviewing the ABG results of a client who the provider suspects has metabolic
acidosis. What would the nurse expect to see?
a) pH above 7.45
b) pH below 7.35
c) pH 7.35 to 7.45
d) pH above 7.50
Answer: b) pH below 7.35
Rationale: Metabolic acidosis results in a decreased blood pH, typically below 7.35.
2. A patient is experiencing shortness of breath (SOB), fatigue, jugular vein distention
(JVD), and the nurse hears a third heart sound (S3). What should the nurse think is the
cause of these symptoms?
a) Pulmonary embolism
b) Heart failure
c) Acute myocardial infarction
d) Asthma exacerbation
Answer: b) Heart failure
Rationale: SOB, fatigue, JVD, and an S3 heart sound are typical signs of heart failure.
3. A nurse is administering potassium chloride elixir 40mEq, divided into 2 equal doses
every 12 hours. The available concentration is 6.7 mEq/5mL. How many mL should the
nurse administer per dose?
a) 20mL
b) 30mL
c) 40mL
d) 50mL
,ESTUDY
Answer: b) 30mL
Rationale: To administer 40mEq in 2 doses (20mEq per dose), the nurse should give 30mL per
dose (6.7 mEq/5mL, so 20mEq = 30mL).
4. A nurse is caring for a patient in the ED with chest pain and possible acute coronary
syndrome. What should the nurse do first?
a) Administer morphine
b) Administer sublingual nitroglycerin
c) Perform an ECG
d) Obtain blood tests
Answer: b) Administer sublingual nitroglycerin
Rationale: Nitroglycerin should be administered first to relieve chest pain and reduce cardiac
tissue damage in suspected acute coronary syndrome.
5. A nurse is caring for a patient with ventricular tachycardia who has a pulse. The Rapid
Response Team (RRT) is at the bedside. What electrical intervention should be used to
correct this dysrhythmia?
a) Defibrillation
b) Synchronized cardioversion
c) Transcutaneous pacing
d) Cardiac massage
Answer: b) Synchronized cardioversion
Rationale: Synchronized cardioversion is used to treat ventricular tachycardia with a pulse and
other arrhythmias like atrial fibrillation and supraventricular tachycardia.
6. A nurse is caring for a patient who is experiencing delayed wound healing. Which
intervention should the nurse take?
a) Apply an antibiotic ointment
b) Increase the patient’s activity level
c) Monitor serum albumin levels and notify the provider if below 3.5g/dL
d) Offer protein shakes to the patient
Answer: c) Monitor serum albumin levels and notify the provider if below 3.5g/dL
Rationale: Low albumin levels can increase the risk of delayed wound healing and infection, so
monitoring is important.
, ESTUDY
7. A nurse is teaching a client with pre-dialysis end-stage kidney disease (ESKD) about diet.
What should be included?
a) Increase protein intake
b) Reduce intake of foods high in potassium
c) Avoid dairy products
d) Limit water intake to prevent dehydration
Answer: b) Reduce intake of foods high in potassium
Rationale: Potassium clearance is impaired in ESKD, and excessive potassium can cause
dangerous heart arrhythmias.
8. A nurse is caring for a patient with Type 1 diabetes mellitus (T1DM). The nurse
misreads the morning blood glucose level as 210mg/dL instead of 120mg/dL and
administers the insulin dose appropriate for a higher reading. What should the nurse do
next?
a) Monitor the patient for hyperglycemia
b) Monitor the patient for hypoglycemia
c) Administer more insulin
d) Withhold insulin
Answer: b) Monitor the patient for hypoglycemia
Rationale: Administering too much insulin based on a misread higher blood glucose level can
cause hypoglycemia, so the nurse should monitor for signs of low blood sugar.
9. A nurse is planning care for a patient with a new diagnosis of diabetes insipidus (DI).
Which intervention should the nurse include?
a) Monitor blood pressure every hour
b) Check urine specific gravity
c) Administer intravenous fluids
d) Restrict fluid intake
Answer: b) Check urine specific gravity
Rationale: Monitoring urine specific gravity helps assess the patient's ability to concentrate
urine, which is impaired in DI.
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