ATI PN CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT
180-Question Practice Examination with Rationales
Correct answers are bolded and underlined. Each item includes a detailed
rationale.
Section 1: Fundamentals, Safety, Perioperative & Fluid/Electrolyte Balance
1. A nurse is preparing to transfer a client who has left-sided weakness from
the bed to a wheelchair. Which action should the nurse take first?
A. Place the wheelchair on the client's right side at a 45-degree angle to the bed
B. Ask the client to stand and pivot on the stronger leg
C. Apply a gait belt around the client's waist
D. Lock the wheels of the bed and the wheelchair
Correct Answer: D. Rationale: Locking the wheels of both the bed and the
wheelchair is the priority safety action because it prevents unexpected
movement of either surface during the transfer, which could cause a fall. Only
after both surfaces are stabilized should the nurse position the chair, apply the
gait belt, and assist the client to stand and pivot toward the stronger side.
2. A nurse is caring for a client who has a serum potassium level of 6.2 mEq/L.
Which finding should the nurse expect?
A. Peaked T waves on the ECG
B. Prolonged QT interval with flattened T waves
C. Positive Trousseau's sign
D. Diminished deep tendon reflexes with muscle weakness only
Correct Answer: A. Rationale: Hyperkalemia (normal range 3.5-5.0 mEq/L)
classically produces peaked, narrow T waves, widened QRS complexes, and
eventually a sine-wave pattern on the ECG due to altered cardiac cell
repolarization. Prolonged QT with flattened T waves is associated with
hypokalemia, not hyperkalemia.
3. A nurse is teaching a client about the use of a surgical incentive spirometer
following abdominal surgery. Which instruction should the nurse include?
A. Exhale forcefully into the device several times per hour
B. Inhale slowly and deeply to raise the indicator, then hold the breath for
3 to 5 seconds
C. Use the device only if the client develops a fever
D. Perform the exercise once daily before discharge teaching
, Correct Answer: B. Rationale: Incentive spirometry works by encouraging a
slow, deep sustained maximal inspiration, which reinflates alveoli and prevents
postoperative atelectasis and pneumonia. Holding the breath at peak inspiration
for 3-5 seconds maximizes alveolar expansion; the device should be used every
1-2 hours while awake, not reserved for fever or performed only once.
4. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client who is 1 day postoperative and reports incisional pain rated 4/10
B. A client who has a new onset of stridor and use of accessory muscles
C. A client who is scheduled for discharge teaching this morning
D. A client who has a low-grade fever of 100.2°F (37.9°C) after surgery
Correct Answer: B. Rationale: Using the airway-breathing-circulation priority
framework, stridor and accessory muscle use indicate an actual or impending
airway obstruction, which is immediately life-threatening and must be
addressed first. The other findings (mild incisional pain, low-grade fever,
routine discharge teaching) are expected or non-urgent and can wait.
5. A nurse is preparing to administer a unit of packed red blood cells. Which
action is the priority prior to initiating the transfusion?
A. Warm the blood in a microwave to body temperature
B. Verify the client's identity and blood product with another nurse per
facility policy
C. Infuse the unit rapidly over 30 minutes
D. Administer diphenhydramine to prevent a transfusion reaction
Correct Answer: B. Rationale: Independent double-checking of client
identity, blood type, and product information by two qualified staff members
immediately before transfusion is the single most important safety step to
prevent a fatal ABO incompatibility reaction. Blood should never be
microwaved, transfusions should run over about 2-4 hours (unless emergent),
and premedication is not routinely required unless prescribed.
6. A nurse is caring for a client who is receiving total parenteral nutrition
(TPN). Which finding requires immediate intervention?
A. Blood glucose of 110 mg/dL
B. Weight gain of 0.5 kg (1.1 lb) in 24 hours
C. Blood glucose of 260 mg/dL
D. Mild redness at the peripheral IV site
Correct Answer: C. Rationale: TPN solutions are high in dextrose and can
precipitate hyperglycemia; a blood glucose of 260 mg/dL is significantly above
the normal range and requires prompt intervention (such as adjusting the
infusion rate or administering insulin per protocol) to prevent hyperosmolar
, complications. A glucose of 110 mg/dL is within acceptable limits, and a 0.5 kg
daily weight gain is an expected therapeutic response to adequate caloric intake.
7. A nurse is assessing a client for stage 2 pressure injury. Which finding is
consistent with this stage?
A. Intact skin with non-blanchable redness
B. Partial-thickness skin loss with exposed pink wound bed, no slough
C. Full-thickness skin loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Correct Answer: B. Rationale: A stage 2 pressure injury involves partial-
thickness loss of the dermis presenting as a shallow open ulcer with a pink or
red wound bed, without slough. Stage 1 shows intact skin with non-blanchable
erythema, stage 3 shows full-thickness loss with visible fat, and stage 4 shows
exposure of bone, tendon, or muscle.
8. A nurse is teaching a client how to use crutches with a three-point gait.
Which instruction should the nurse include?
A. Move both crutches and the affected leg forward together, then move
the unaffected leg
B. Move both crutches forward, then move both legs together
C. Advance one crutch, then the opposite leg, alternating sides
D. Move the affected leg first, followed by both crutches
Correct Answer: A. Rationale: In a three-point gait, used when one leg cannot
bear full weight, the client advances both crutches and the affected leg
simultaneously, then swings the unaffected leg forward, which allows the
stronger leg to bear the client's weight while the crutches and weaker leg move
as a unit.
9. A nurse is caring for a client who has a nasogastric tube connected to low
intermittent suction and reports nausea with no drainage noted for 2 hours.
Which action should the nurse take first?
A. Notify the provider immediately
B. Check the tube for proper placement and patency, including irrigation if
indicated
C. Increase the suction setting to high continuous
D. Remove the tube and reinsert a new one
Correct Answer: B. Rationale: The first step when a NG tube on suction stops
draining is to assess and troubleshoot the existing tube for kinking, clogging, or
displacement, including gentle irrigation with normal saline per protocol, since
this is a common and easily correctable cause. Increasing suction to high
continuous can cause mucosal damage, and removal/reinsertion or notifying the
provider are appropriate only after basic troubleshooting fails.
, 10. A nurse is caring for a client who has a serum sodium level of 122 mEq/L.
Which manifestation should the nurse expect?
A. Muscle twitching and confusion
B. Peripheral edema with bounding pulses only
C. Hyperreflexia and tetany
D. Polyuria with intense thirst
Correct Answer: A. Rationale: Hyponatremia (normal 136-145 mEq/L)
causes cellular swelling, particularly in neurologic tissue, leading to confusion,
lethargy, headache, and muscle twitching or seizures in severe cases.
Hyperreflexia/tetany are more typical of hypocalcemia, and polyuria with thirst
is characteristic of diabetes insipidus or hyperglycemia rather than
hyponatremia.
11. A nurse is caring for a client immediately after a liver biopsy. Which
position should the nurse place the client in?
A. Left side-lying with a pillow under the puncture site
B. Right side-lying with a pillow or rolled towel against the puncture site
C. High Fowler's position with legs extended
D. Prone position for 4 hours
Correct Answer: B. Rationale: After a liver biopsy, the client should be
positioned on the right side with a pillow or rolled towel pressed against the
puncture site for at least 1-2 hours; this applies direct pressure against the liver
capsule and rib cage to reduce the risk of bleeding, since the liver is a highly
vascular organ.
12. A nurse is caring for a client who is 4 hours postoperative following
abdominal surgery and has scant serosanguineous drainage on the dressing.
Which action should the nurse take?
A. Remove the dressing and inspect the incision directly
B. Reinforce the dressing and continue to monitor
C. Notify the surgeon immediately for suspected hemorrhage
D. Apply an ice pack directly over the dressing
Correct Answer: B. Rationale: Scant serosanguineous drainage in the early
postoperative period is an expected finding; the appropriate action is to
reinforce the existing dressing and continue routine monitoring for changes in
amount, color, or odor, rather than removing the original dressing (which the
surgeon typically changes) or assuming hemorrhage from an expected amount
of drainage.
13. A nurse is caring for a client who has a chest tube attached to a closed
water-seal drainage system. The nurse notes continuous bubbling in the
water-seal chamber. Which action should the nurse take?
ASSESSMENT
180-Question Practice Examination with Rationales
Correct answers are bolded and underlined. Each item includes a detailed
rationale.
Section 1: Fundamentals, Safety, Perioperative & Fluid/Electrolyte Balance
1. A nurse is preparing to transfer a client who has left-sided weakness from
the bed to a wheelchair. Which action should the nurse take first?
A. Place the wheelchair on the client's right side at a 45-degree angle to the bed
B. Ask the client to stand and pivot on the stronger leg
C. Apply a gait belt around the client's waist
D. Lock the wheels of the bed and the wheelchair
Correct Answer: D. Rationale: Locking the wheels of both the bed and the
wheelchair is the priority safety action because it prevents unexpected
movement of either surface during the transfer, which could cause a fall. Only
after both surfaces are stabilized should the nurse position the chair, apply the
gait belt, and assist the client to stand and pivot toward the stronger side.
2. A nurse is caring for a client who has a serum potassium level of 6.2 mEq/L.
Which finding should the nurse expect?
A. Peaked T waves on the ECG
B. Prolonged QT interval with flattened T waves
C. Positive Trousseau's sign
D. Diminished deep tendon reflexes with muscle weakness only
Correct Answer: A. Rationale: Hyperkalemia (normal range 3.5-5.0 mEq/L)
classically produces peaked, narrow T waves, widened QRS complexes, and
eventually a sine-wave pattern on the ECG due to altered cardiac cell
repolarization. Prolonged QT with flattened T waves is associated with
hypokalemia, not hyperkalemia.
3. A nurse is teaching a client about the use of a surgical incentive spirometer
following abdominal surgery. Which instruction should the nurse include?
A. Exhale forcefully into the device several times per hour
B. Inhale slowly and deeply to raise the indicator, then hold the breath for
3 to 5 seconds
C. Use the device only if the client develops a fever
D. Perform the exercise once daily before discharge teaching
, Correct Answer: B. Rationale: Incentive spirometry works by encouraging a
slow, deep sustained maximal inspiration, which reinflates alveoli and prevents
postoperative atelectasis and pneumonia. Holding the breath at peak inspiration
for 3-5 seconds maximizes alveolar expansion; the device should be used every
1-2 hours while awake, not reserved for fever or performed only once.
4. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client who is 1 day postoperative and reports incisional pain rated 4/10
B. A client who has a new onset of stridor and use of accessory muscles
C. A client who is scheduled for discharge teaching this morning
D. A client who has a low-grade fever of 100.2°F (37.9°C) after surgery
Correct Answer: B. Rationale: Using the airway-breathing-circulation priority
framework, stridor and accessory muscle use indicate an actual or impending
airway obstruction, which is immediately life-threatening and must be
addressed first. The other findings (mild incisional pain, low-grade fever,
routine discharge teaching) are expected or non-urgent and can wait.
5. A nurse is preparing to administer a unit of packed red blood cells. Which
action is the priority prior to initiating the transfusion?
A. Warm the blood in a microwave to body temperature
B. Verify the client's identity and blood product with another nurse per
facility policy
C. Infuse the unit rapidly over 30 minutes
D. Administer diphenhydramine to prevent a transfusion reaction
Correct Answer: B. Rationale: Independent double-checking of client
identity, blood type, and product information by two qualified staff members
immediately before transfusion is the single most important safety step to
prevent a fatal ABO incompatibility reaction. Blood should never be
microwaved, transfusions should run over about 2-4 hours (unless emergent),
and premedication is not routinely required unless prescribed.
6. A nurse is caring for a client who is receiving total parenteral nutrition
(TPN). Which finding requires immediate intervention?
A. Blood glucose of 110 mg/dL
B. Weight gain of 0.5 kg (1.1 lb) in 24 hours
C. Blood glucose of 260 mg/dL
D. Mild redness at the peripheral IV site
Correct Answer: C. Rationale: TPN solutions are high in dextrose and can
precipitate hyperglycemia; a blood glucose of 260 mg/dL is significantly above
the normal range and requires prompt intervention (such as adjusting the
infusion rate or administering insulin per protocol) to prevent hyperosmolar
, complications. A glucose of 110 mg/dL is within acceptable limits, and a 0.5 kg
daily weight gain is an expected therapeutic response to adequate caloric intake.
7. A nurse is assessing a client for stage 2 pressure injury. Which finding is
consistent with this stage?
A. Intact skin with non-blanchable redness
B. Partial-thickness skin loss with exposed pink wound bed, no slough
C. Full-thickness skin loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Correct Answer: B. Rationale: A stage 2 pressure injury involves partial-
thickness loss of the dermis presenting as a shallow open ulcer with a pink or
red wound bed, without slough. Stage 1 shows intact skin with non-blanchable
erythema, stage 3 shows full-thickness loss with visible fat, and stage 4 shows
exposure of bone, tendon, or muscle.
8. A nurse is teaching a client how to use crutches with a three-point gait.
Which instruction should the nurse include?
A. Move both crutches and the affected leg forward together, then move
the unaffected leg
B. Move both crutches forward, then move both legs together
C. Advance one crutch, then the opposite leg, alternating sides
D. Move the affected leg first, followed by both crutches
Correct Answer: A. Rationale: In a three-point gait, used when one leg cannot
bear full weight, the client advances both crutches and the affected leg
simultaneously, then swings the unaffected leg forward, which allows the
stronger leg to bear the client's weight while the crutches and weaker leg move
as a unit.
9. A nurse is caring for a client who has a nasogastric tube connected to low
intermittent suction and reports nausea with no drainage noted for 2 hours.
Which action should the nurse take first?
A. Notify the provider immediately
B. Check the tube for proper placement and patency, including irrigation if
indicated
C. Increase the suction setting to high continuous
D. Remove the tube and reinsert a new one
Correct Answer: B. Rationale: The first step when a NG tube on suction stops
draining is to assess and troubleshoot the existing tube for kinking, clogging, or
displacement, including gentle irrigation with normal saline per protocol, since
this is a common and easily correctable cause. Increasing suction to high
continuous can cause mucosal damage, and removal/reinsertion or notifying the
provider are appropriate only after basic troubleshooting fails.
, 10. A nurse is caring for a client who has a serum sodium level of 122 mEq/L.
Which manifestation should the nurse expect?
A. Muscle twitching and confusion
B. Peripheral edema with bounding pulses only
C. Hyperreflexia and tetany
D. Polyuria with intense thirst
Correct Answer: A. Rationale: Hyponatremia (normal 136-145 mEq/L)
causes cellular swelling, particularly in neurologic tissue, leading to confusion,
lethargy, headache, and muscle twitching or seizures in severe cases.
Hyperreflexia/tetany are more typical of hypocalcemia, and polyuria with thirst
is characteristic of diabetes insipidus or hyperglycemia rather than
hyponatremia.
11. A nurse is caring for a client immediately after a liver biopsy. Which
position should the nurse place the client in?
A. Left side-lying with a pillow under the puncture site
B. Right side-lying with a pillow or rolled towel against the puncture site
C. High Fowler's position with legs extended
D. Prone position for 4 hours
Correct Answer: B. Rationale: After a liver biopsy, the client should be
positioned on the right side with a pillow or rolled towel pressed against the
puncture site for at least 1-2 hours; this applies direct pressure against the liver
capsule and rib cage to reduce the risk of bleeding, since the liver is a highly
vascular organ.
12. A nurse is caring for a client who is 4 hours postoperative following
abdominal surgery and has scant serosanguineous drainage on the dressing.
Which action should the nurse take?
A. Remove the dressing and inspect the incision directly
B. Reinforce the dressing and continue to monitor
C. Notify the surgeon immediately for suspected hemorrhage
D. Apply an ice pack directly over the dressing
Correct Answer: B. Rationale: Scant serosanguineous drainage in the early
postoperative period is an expected finding; the appropriate action is to
reinforce the existing dressing and continue routine monitoring for changes in
amount, color, or odor, rather than removing the original dressing (which the
surgeon typically changes) or assuming hemorrhage from an expected amount
of drainage.
13. A nurse is caring for a client who has a chest tube attached to a closed
water-seal drainage system. The nurse notes continuous bubbling in the
water-seal chamber. Which action should the nurse take?
