NSG 4060 ATI Capstone
Comprehensive Assessment Proctored
Exam:The Ultimate -Question Review
with Evidence-Based Rationales for
RN Students
1. A nurse is assessing a client who received 2 units of packed RBCs 48
hours ago. Which of the following findings should indicate to the
nurse that the therapy has been effective?
Answer: Hemoglobin 14.9 g/dL
Rationale: Packed RBCs are administered to clients who have a decreased
level of hemoglobin or hematocrit. A hemoglobin level within the expected
reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females
indicates the therapy has been effective.
2. A nurse is teaching a client who has a new prescription for
metformin extended-release tablets. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: "I will avoid crushing this medication"
Rationale: Extended-release medications should not be crushed or chewed
as this destroys the extended-release mechanism and can cause a rapid
release of the medication, potentially leading to toxicity or adverse effects.
The tablet should be swallowed whole.
,3. A nurse is caring for a client with chest pain who is experiencing
diaphoresis and nausea. Which action should the nurse take first?
Answer: Assess the client immediately
Rationale: Chest pain with diaphoresis and nausea are classic signs of
myocardial infarction, indicating an immediate life-threatening emergency
requiring priority assessment. This client should be assessed before clients
with stable conditions.
4. A nurse is preparing to administer medications to a client. Which
method should the nurse use to verify client identity?
Answer: Name and date of birth
Rationale: The two acceptable identifiers are the client's name and date of
birth (or another approved identifier like medical record number). Room
and bed numbers are not reliable identifiers as clients may move between
rooms.
5. A nurse is caring for a client who is at risk for falls. Which action
should the nurse take?
Answer: Keep the bed in the lowest position with side rails up
Rationale: Keeping the bed in the lowest position with side rails up is a
safe intervention to prevent falls. Physical restraints are a last resort and
require a provider's order. Call lights should be within reach, and clients
should never be left unattended.
6. A charge nurse is assigning client care to a team consisting of an RN,
an LPN, and a UAP. Which client should the charge nurse assign to the
LPN?
,Answer: A client who has a urinary tract infection and requires a urine
culture
Rationale: LPNs are licensed to perform stable, predictable tasks including
specimen collection and urinary catheterization. The client with a UTI
requiring a urine culture is stable and within LPN scope. Postoperative
clients, stroke clients requiring frequent neurological assessments, and
clients receiving blood transfusions require RN care.
7. A nurse is delegating tasks to unlicensed assistive personnel (UAP).
Which task should the nurse delegate?
Answer: Assisting a client with feeding
Rationale: Assisting with feeding is within the scope of UAP. Administering
oral medications, performing sterile dressing changes, and assessing
wounds require licensed nursing judgment and cannot be delegated to
UAP.
8. A nurse is assessing a child who is post-operative following a
tonsillectomy. Which finding should the nurse identify as the priority?
Answer: Frequent swallowing
Rationale: Frequent swallowing after a tonsillectomy can indicate bleeding,
as the child may be swallowing blood. This is a priority finding that requires
immediate assessment and intervention.
9. A nurse is monitoring a client who is receiving a transfusion of
packed RBCs. The client reports chills, headache, low back pain, and
chest tightness. Which type of transfusion reaction has developed?
Answer: Acute hemolytic reaction
, Rationale: Acute hemolytic transfusion reactions occur when the recipient's
antibodies attack the donor's RBCs. Symptoms include chills, fever, low
back pain, chest tightness, and hypotension. This is a medical emergency
requiring immediate discontinuation of the transfusion.
10. A client with depression says, "Life isn't worth living anymore."
What is the nurse's priority response?
Answer: "Have you thought about how you would kill yourself?"
Rationale: This question directly assesses the client's risk for suicide. A
client who expresses suicidal ideation requires a direct assessment of their
plan, intent, and means. This is the priority nursing action to ensure client
safety.
11. A client who is 24 hours postoperative following abdominal
surgery refuses to ambulate. Which action should the nurse take first?
Answer: Ask the client to rate their pain level
Rationale: Pain is a common reason clients refuse to ambulate
postoperatively. Assessing pain first allows the nurse to address the
underlying cause and implement appropriate interventions such as
administering pain medication before encouraging ambulation.
12. A nurse is caring for a client who had abdominal surgery 24 hours
ago. Which action is the nurse's priority?
Answer: Assist with deep breathing and coughing
Rationale: The priority is to prevent postoperative pulmonary
complications. Deep breathing and coughing exercises help expand the
lungs and prevent atelectasis and pneumonia, which are significant
postoperative risks.
Comprehensive Assessment Proctored
Exam:The Ultimate -Question Review
with Evidence-Based Rationales for
RN Students
1. A nurse is assessing a client who received 2 units of packed RBCs 48
hours ago. Which of the following findings should indicate to the
nurse that the therapy has been effective?
Answer: Hemoglobin 14.9 g/dL
Rationale: Packed RBCs are administered to clients who have a decreased
level of hemoglobin or hematocrit. A hemoglobin level within the expected
reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females
indicates the therapy has been effective.
2. A nurse is teaching a client who has a new prescription for
metformin extended-release tablets. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: "I will avoid crushing this medication"
Rationale: Extended-release medications should not be crushed or chewed
as this destroys the extended-release mechanism and can cause a rapid
release of the medication, potentially leading to toxicity or adverse effects.
The tablet should be swallowed whole.
,3. A nurse is caring for a client with chest pain who is experiencing
diaphoresis and nausea. Which action should the nurse take first?
Answer: Assess the client immediately
Rationale: Chest pain with diaphoresis and nausea are classic signs of
myocardial infarction, indicating an immediate life-threatening emergency
requiring priority assessment. This client should be assessed before clients
with stable conditions.
4. A nurse is preparing to administer medications to a client. Which
method should the nurse use to verify client identity?
Answer: Name and date of birth
Rationale: The two acceptable identifiers are the client's name and date of
birth (or another approved identifier like medical record number). Room
and bed numbers are not reliable identifiers as clients may move between
rooms.
5. A nurse is caring for a client who is at risk for falls. Which action
should the nurse take?
Answer: Keep the bed in the lowest position with side rails up
Rationale: Keeping the bed in the lowest position with side rails up is a
safe intervention to prevent falls. Physical restraints are a last resort and
require a provider's order. Call lights should be within reach, and clients
should never be left unattended.
6. A charge nurse is assigning client care to a team consisting of an RN,
an LPN, and a UAP. Which client should the charge nurse assign to the
LPN?
,Answer: A client who has a urinary tract infection and requires a urine
culture
Rationale: LPNs are licensed to perform stable, predictable tasks including
specimen collection and urinary catheterization. The client with a UTI
requiring a urine culture is stable and within LPN scope. Postoperative
clients, stroke clients requiring frequent neurological assessments, and
clients receiving blood transfusions require RN care.
7. A nurse is delegating tasks to unlicensed assistive personnel (UAP).
Which task should the nurse delegate?
Answer: Assisting a client with feeding
Rationale: Assisting with feeding is within the scope of UAP. Administering
oral medications, performing sterile dressing changes, and assessing
wounds require licensed nursing judgment and cannot be delegated to
UAP.
8. A nurse is assessing a child who is post-operative following a
tonsillectomy. Which finding should the nurse identify as the priority?
Answer: Frequent swallowing
Rationale: Frequent swallowing after a tonsillectomy can indicate bleeding,
as the child may be swallowing blood. This is a priority finding that requires
immediate assessment and intervention.
9. A nurse is monitoring a client who is receiving a transfusion of
packed RBCs. The client reports chills, headache, low back pain, and
chest tightness. Which type of transfusion reaction has developed?
Answer: Acute hemolytic reaction
, Rationale: Acute hemolytic transfusion reactions occur when the recipient's
antibodies attack the donor's RBCs. Symptoms include chills, fever, low
back pain, chest tightness, and hypotension. This is a medical emergency
requiring immediate discontinuation of the transfusion.
10. A client with depression says, "Life isn't worth living anymore."
What is the nurse's priority response?
Answer: "Have you thought about how you would kill yourself?"
Rationale: This question directly assesses the client's risk for suicide. A
client who expresses suicidal ideation requires a direct assessment of their
plan, intent, and means. This is the priority nursing action to ensure client
safety.
11. A client who is 24 hours postoperative following abdominal
surgery refuses to ambulate. Which action should the nurse take first?
Answer: Ask the client to rate their pain level
Rationale: Pain is a common reason clients refuse to ambulate
postoperatively. Assessing pain first allows the nurse to address the
underlying cause and implement appropriate interventions such as
administering pain medication before encouraging ambulation.
12. A nurse is caring for a client who had abdominal surgery 24 hours
ago. Which action is the nurse's priority?
Answer: Assist with deep breathing and coughing
Rationale: The priority is to prevent postoperative pulmonary
complications. Deep breathing and coughing exercises help expand the
lungs and prevent atelectasis and pneumonia, which are significant
postoperative risks.
