Assessment 1 Questions and Answers

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Capstone ATI NCLEX Medical Surgical Assessment 1 Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

A client with COPD is receiving oxygen via nasal cannula at 4 L/min. Which action should the nurse take first?

• Encourage pursed-lip breathing

✔✔ B. Reduce the oxygen flow rate

• Assess temperature
• Elevate the client's legs

A nurse is caring for a client post-hip replacement who suddenly complains of shortness of breath and chest pain. What should the nurse suspect?✔✔ A. Pulmonary embolism

• Myocardial infarction
• Atelectasis
• Pneumonia
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A nurse is assessing a client with left-sided heart failure. Which finding should be reported immediately?

• Fatigue and weakness
• Nocturia

✔✔ C. Frothy pink sputum

• Cool extremities

Which food should be avoided by a client taking warfarin?✔✔ A. Spinach

• Chicken breast
• Bananas
• Applesauce

A client with diabetes has a fasting glucose of 64 mg/dL. Which action should the nurse take?✔✔ A. Administer 15g of glucose

• Notify the provider
• Recheck in 2 hours
• Give sliding scale insulin 2 / 4

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A nurse is monitoring a client following thyroidectomy. Which finding should be reported immediately?

• Hoarse voice

✔✔ B. Tingling around the mouth

• Pain at the incision site
• Slight swelling around the neck

A client with a DVT is receiving IV heparin. Which lab result requires intervention?

A. INR 1.1

✔✔ B. aPTT 110 seconds

• Platelets 200,000
• Hemoglobin 13.4

A nurse is caring for a client with cirrhosis who is at risk for hepatic encephalopathy. Which dietary instruction is appropriate?✔✔ A. Reduce protein intake

• Increase calcium 3 / 4

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• Limit carbohydrates
• Avoid sodium

A client receiving chemotherapy reports mouth sores and difficulty eating. What should the nurse recommend?

• Use mouthwash with alcohol

✔✔ B. Rinse mouth with saline

• Eat spicy foods to stimulate taste
• Brush teeth with firm-bristled brush

A nurse is assessing a client with peritonitis. Which finding requires immediate action?

• Nausea and vomiting
• Firm abdomen

✔✔ C. Absent bowel sounds

• Fever of 38.1°C (100.6°F)

Which of the following clients is at highest risk for skin breakdown?

• Ambulatory with urinary incontinence
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