ATI RN CAPSTONE MEDICAL SURGICAL ASSESSMENT 2024-2025
|ACTUAL COMPLETE EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS ) ALREADY GRADED A+.
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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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" -
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" -
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
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