ATI Capstone Adult Medical Surgical Assessment 3

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Sample questions from ATI Capstone Adult Medical Surgical Assessment 3

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A client with acute heart failure is receiving IV furosemide. Which finding requires the nurse to intervene first?

   • A.Urine output of 900 mL over 4 hours
   • B.Potassium level of 2.8 mEq/L
   • C.Blood pressure of 138/82 mm Hg
   • D.Weight decrease of 0.8 kg in 24 hours

   Rationale: A potassium level of 2.8 mEq/L places the client at risk for life-threatening dysrhythmias and requires prompt notification and intervention. Increased urine output and a modest weight decrease are expected responses to diuresis, while the blood pressure is not critically low. The exam takeaway is to prioritize dangerous electrolyte abnormalities over expected therapeutic effects.

2. 2.A client with chest pain has a prescription for sublingual nitroglycerin. Which assessment finding should cause the nurse to withhold the medication and notify the provider?

   • A.Heart rate of 96/min
   • B.Blood pressure of 86/54 mm Hg
   • C.Pain rated 8 on a scale of 0 to 10
   • D.Oxygen saturation of 95% on room air

   Rationale: Nitroglycerin can further lower blood pressure, so a pressure of 86/54 mm Hg makes administration unsafe. Tachycardia, severe chest pain, and an oxygen saturation of 95% do not independently contraindicate the medication. The exam takeaway is to check blood pressure before administering nitrates.

3. 3.A nurse is caring for a client with COPD who is receiving oxygen by nasal cannula. Which finding best indicates that the oxygen therapy is effective?

   • A.The client is alert and the oxygen saturation is 90%
   • B.The client reports a dry mouth
   • C.The respiratory rate increases from 20 to 28/min
   • D.The client becomes difficult to arouse

   Rationale: For many clients with COPD, an oxygen saturation around 88% to 92% is an appropriate target when prescribed, and improved alertness indicates adequate oxygenation. Dry mouth can occur with oxygen therapy but does not establish effectiveness. Increasing respiratory rate or decreasing level of consciousness suggests deterioration, not a desired response.

4. 4.A client with diabetic ketoacidosis is receiving IV regular insulin and isotonic fluids. Which laboratory result requires immediate action?

   • A.Glucose 260 mg/dL
   • B.Potassium 3.1 mEq/L
   • C.Sodium 134 mEq/L
   • D.Bicarbonate 17 mEq/L

   Answer and rationale are in the full material.

5. 5.A client with a suspected ischemic stroke arrives in the emergency department. Which information is most important to obtain before determining eligibility for thrombolytic therapy?

   • A.The client's usual daily fluid intake
   • B.The exact time the client was last known to be well
   • C.Whether the client has a history of seasonal allergies
   • D.The client's preferred pharmacy

   Answer and rationale are in the full material.