ATI RN Capstone Comprehensive
Assessment A Exam Questions and
Correct Answers (Verified Answers) Plus
Rationales | 2026 /2027 Q&A | Instant
Download Pdf.
1.
A nurse is caring for a client who is 2 hours postoperative following a
total hip arthroplasty. Which finding requires immediate intervention?
A. Pain rating of 6/10
B. Urine output of 40 mL/hr
C. Oxygen saturation of 89% on room air
D. Temperature of 37.6°C (99.7°F)
Answer: C. Oxygen saturation of 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention, particularly in a
postoperative client who is at risk for respiratory complications. The
nurse should assess airway and breathing, apply oxygen as prescribed,
and investigate possible causes such as atelectasis, opioid-induced
respiratory depression, or pulmonary embolism. Moderate
postoperative pain, urine output of 40 mL/hr, and a temperature of
37.6°C are not immediately concerning.
,2.
A nurse is assessing a client with heart failure. Which finding is most
indicative of worsening left-sided heart failure?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Weight gain of 1 kg (2.2 lb) in 1 week
Answer: C. Crackles in the lung bases
Rationale: Crackles occur when fluid accumulates in the alveoli and are
characteristic of pulmonary congestion associated with left-sided heart
failure. Peripheral edema, jugular venous distention, and weight gain
are more commonly associated with systemic venous congestion and
right-sided heart failure, although they can occur with overall heart
failure.
3.
A nurse is caring for a client who has a prescription for digoxin. Which
finding should cause the nurse to withhold the medication and notify
the provider?
A. Apical pulse of 54/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: A. Apical pulse of 54/min
,Rationale: Digoxin can cause bradycardia because it slows
atrioventricular conduction. The nurse should generally withhold digoxin
and notify the provider when the adult client's apical pulse is below
60/min. A normal potassium level and the listed blood pressure and
respiratory rate do not independently require withholding the
medication.
4.
A client with type 1 diabetes mellitus is admitted with diabetic
ketoacidosis (DKA). Which prescription should the nurse implement
first?
A. Administer IV regular insulin
B. Begin IV isotonic fluid replacement
C. Administer potassium chloride
D. Initiate a dextrose-containing IV solution
Answer: B. Begin IV isotonic fluid replacement
Rationale: Severe dehydration caused by osmotic diuresis is a major
problem in DKA. Initial treatment focuses on restoring circulating
volume with isotonic IV fluids, typically 0.9% sodium chloride. Insulin is
then administered to stop ketone production and reduce glucose.
Potassium replacement is based on the serum potassium level and renal
function. Dextrose is added later when blood glucose falls to prevent
hypoglycemia while insulin continues to clear ketones.
5.
, A nurse is teaching a client who is taking warfarin. Which statement
indicates that the client understands the teaching?
A. "I should completely avoid foods containing vitamin K."
B. "I can take aspirin whenever I have a headache."
C. "I should keep my intake of vitamin K-containing foods consistent."
D. "I should stop taking warfarin when my bruising improves."
Answer: C. "I should keep my intake of vitamin K-containing foods
consistent."
Rationale: Warfarin interferes with vitamin K-dependent clotting factors.
Clients should maintain a consistent intake of vitamin K rather than
eliminate vitamin K-containing foods. Aspirin can increase bleeding risk
and should not be taken unless specifically prescribed. Warfarin should
not be stopped based on symptoms; therapy is adjusted according to
coagulation monitoring and the prescribed treatment plan.
6.
A nurse is caring for a client who has a potassium level of 2.8 mEq/L.
Which finding should the nurse expect?
A. Hyperactive deep-tendon reflexes
B. Muscle weakness
C. Bounding peripheral pulses
D. Increased bowel motility
Answer: B. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, leg
cramps, decreased gastrointestinal motility, and cardiac dysrhythmias.
Assessment A Exam Questions and
Correct Answers (Verified Answers) Plus
Rationales | 2026 /2027 Q&A | Instant
Download Pdf.
1.
A nurse is caring for a client who is 2 hours postoperative following a
total hip arthroplasty. Which finding requires immediate intervention?
A. Pain rating of 6/10
B. Urine output of 40 mL/hr
C. Oxygen saturation of 89% on room air
D. Temperature of 37.6°C (99.7°F)
Answer: C. Oxygen saturation of 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention, particularly in a
postoperative client who is at risk for respiratory complications. The
nurse should assess airway and breathing, apply oxygen as prescribed,
and investigate possible causes such as atelectasis, opioid-induced
respiratory depression, or pulmonary embolism. Moderate
postoperative pain, urine output of 40 mL/hr, and a temperature of
37.6°C are not immediately concerning.
,2.
A nurse is assessing a client with heart failure. Which finding is most
indicative of worsening left-sided heart failure?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Weight gain of 1 kg (2.2 lb) in 1 week
Answer: C. Crackles in the lung bases
Rationale: Crackles occur when fluid accumulates in the alveoli and are
characteristic of pulmonary congestion associated with left-sided heart
failure. Peripheral edema, jugular venous distention, and weight gain
are more commonly associated with systemic venous congestion and
right-sided heart failure, although they can occur with overall heart
failure.
3.
A nurse is caring for a client who has a prescription for digoxin. Which
finding should cause the nurse to withhold the medication and notify
the provider?
A. Apical pulse of 54/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: A. Apical pulse of 54/min
,Rationale: Digoxin can cause bradycardia because it slows
atrioventricular conduction. The nurse should generally withhold digoxin
and notify the provider when the adult client's apical pulse is below
60/min. A normal potassium level and the listed blood pressure and
respiratory rate do not independently require withholding the
medication.
4.
A client with type 1 diabetes mellitus is admitted with diabetic
ketoacidosis (DKA). Which prescription should the nurse implement
first?
A. Administer IV regular insulin
B. Begin IV isotonic fluid replacement
C. Administer potassium chloride
D. Initiate a dextrose-containing IV solution
Answer: B. Begin IV isotonic fluid replacement
Rationale: Severe dehydration caused by osmotic diuresis is a major
problem in DKA. Initial treatment focuses on restoring circulating
volume with isotonic IV fluids, typically 0.9% sodium chloride. Insulin is
then administered to stop ketone production and reduce glucose.
Potassium replacement is based on the serum potassium level and renal
function. Dextrose is added later when blood glucose falls to prevent
hypoglycemia while insulin continues to clear ketones.
5.
, A nurse is teaching a client who is taking warfarin. Which statement
indicates that the client understands the teaching?
A. "I should completely avoid foods containing vitamin K."
B. "I can take aspirin whenever I have a headache."
C. "I should keep my intake of vitamin K-containing foods consistent."
D. "I should stop taking warfarin when my bruising improves."
Answer: C. "I should keep my intake of vitamin K-containing foods
consistent."
Rationale: Warfarin interferes with vitamin K-dependent clotting factors.
Clients should maintain a consistent intake of vitamin K rather than
eliminate vitamin K-containing foods. Aspirin can increase bleeding risk
and should not be taken unless specifically prescribed. Warfarin should
not be stopped based on symptoms; therapy is adjusted according to
coagulation monitoring and the prescribed treatment plan.
6.
A nurse is caring for a client who has a potassium level of 2.8 mEq/L.
Which finding should the nurse expect?
A. Hyperactive deep-tendon reflexes
B. Muscle weakness
C. Bounding peripheral pulses
D. Increased bowel motility
Answer: B. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, leg
cramps, decreased gastrointestinal motility, and cardiac dysrhythmias.
