ATI Capstone Adult Medical Surgical Assessment 2

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Sample questions from ATI Capstone Adult Medical Surgical Assessment 2

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

1. 1.A nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client with COPD whose oxygen saturation is 90% on the prescribed oxygen
   • B.A client 2 hours after thyroidectomy who is restless and has audible stridor
   • C.A client with heart failure who has bilateral ankle edema
   • D.A client with diabetes whose blood glucose is 248 mg/dL before lunch

   Rationale: Stridor after thyroidectomy suggests airway obstruction from laryngeal edema or a neck hematoma and requires immediate intervention. The COPD client's saturation may be within the prescribed target, while edema and hyperglycemia need follow-up but are not immediate airway threats. Use the airway-breathing-circulation framework to prioritize rapidly worsening airway findings.

2. 2.A client with a suspected acute stroke arrives in the emergency department. Which action should the nurse anticipate first?

   • A.Administer aspirin before diagnostic testing
   • B.Obtain a noncontrast CT scan of the head
   • C.Begin oral fluids to assess swallowing
   • D.Lower the blood pressure to a normal range immediately

   Rationale: A noncontrast head CT is needed promptly to distinguish ischemic from hemorrhagic stroke before treatment decisions are made. Aspirin is not given until hemorrhage is excluded, and oral intake is unsafe until swallowing is evaluated. Blood pressure is managed according to stroke-specific parameters rather than lowered automatically to normal.

3. 3.A client with diabetic ketoacidosis has a serum potassium of 3.1 mEq/L and an insulin infusion is prescribed. Which action should the nurse take?

   • A.Start the insulin infusion and recheck potassium in 1 hour
   • B.Hold insulin and anticipate potassium replacement
   • C.Administer sodium bicarbonate before insulin
   • D.Restrict potassium-containing fluids

   Rationale: Insulin shifts potassium into cells and can worsen hypokalemia, so potassium must be corrected before insulin is started when the level is this low. Starting insulin immediately risks life-threatening dysrhythmias. Bicarbonate is not routinely indicated, and restricting potassium would worsen the deficit.

4. 4.A client with a new prescription for warfarin asks which food choice is most appropriate. Which response should the nurse make?

   • A.Avoid all foods that contain vitamin K
   • B.Keep the intake of vitamin K-containing foods consistent
   • C.Increase intake of spinach when the INR is above target
   • D.Take an extra dose after eating a large serving of broccoli

   Answer and rationale are in the full material.

5. 5.A nurse is caring for a client with chest pain who is prescribed sublingual nitroglycerin. Which finding requires the nurse to withhold the medication and notify the provider?

   • A.The client took sildenafil 8 hours ago
   • B.The client reports a headache after the first dose
   • C.The client's heart rate is 88/min
   • D.The client is sitting upright in bed

   Answer and rationale are in the full material.