RN ATI capstone proctored
comprehensive assessment 2019 B
1. A charge nurse is making client assignments on a medical-surgical unit. Which client should
the nurse assign to the LPN/LVN?
A. A client 4 hours post-cardiac catheterization with a femoral sheath
B. A client requiring a blood transfusion for chronic anemia
C. A client with a stable sacral pressure injury requiring a dressing change
D. A client newly admitted with chest pain and an elevated troponin
C. A client with a stable sacral pressure injury requiring a dressing change
LPN/LVNs can perform stable, predictable tasks such as dressing changes on chronic
wounds. A (post-catheterization with sheath) and D (new admission with possible ACS) require
RN assessment and monitoring; B (blood transfusion) requires RN assessment for transfusion
reactions.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Ambulating a client 1 day post-op total hip arthroplasty
B. Obtaining a stool specimen from a client with diarrhea
C. Teaching a client how to use an incentive spirometer
D. Assessing a client's incision for signs of infection
B. Obtaining a stool specimen from a client with diarrhea
Collecting a specimen is a standard, non-assessment task within UAP scope. A requires
RN/LPN evaluation of fall risk and surgical precautions; C is teaching (RN only); D is assessment
(RN only).
3. A nurse is caring for a client who speaks limited English and needs to sign informed
consent. Which action should the nurse take?
A. Ask the client's adult child to interpret
B. Use the facility's trained medical interpreter
C. Have the client sign the English consent and explain later
D. Use a bilingual UAP to interpret
, B. Use the facility's trained medical interpreter
Federal law and best practice require trained medical interpreters for informed consent.
Family members (A) may filter information, create conflict of interest, and are not trained; C
invalidates informed consent; D exceeds UAP scope and training.
4. A nurse is reviewing advance directives with a newly admitted client. Which statement
indicates the client understands a durable power of attorney for health care?
A. "It tells my doctor what treatments I want."
B. "It names the person who can make decisions if I can't."
C. "It's the same as a do-not-resuscitate order."
D. "It only takes effect after I die."
B. "It names the person who can make decisions if I can't."
A durable power of attorney for health care designates a surrogate decision-maker. A
describes a living will; C confuses it with a DNR; D describes a will/executor, not a healthcare
proxy.
5. A nurse is prioritizing care for four clients. Which client should the nurse see first?
A. A client with COPD reporting a new productive cough
B. A client 2 days post-op reporting incisional pain 4/10
C. A client with diabetes requesting a snack
D. A client with a new onset of confusion and BP 88/54 mm Hg
D. A client with a new onset of confusion and BP 88/54 mm Hg
New confusion with hypotension suggests decreased perfusion (e.g., sepsis, hemorrhage) —
a life-threatening priority. A is important but stable; B and C are routine needs.
6. A nurse is preparing to discharge a client who will receive home IV antibiotics via a
peripherally inserted central catheter (PICC). Which referral is the priority?
A. Physical therapy
B. Home health nursing
C. Occupational therapy
D. Social work
B. Home health nursing
Home health nursing provides skilled assessment, catheter care, and IV antibiotic
,administration in the home. PT/OT address mobility/ADLs; social work addresses resources —
none manage the PICC or infusion.
7. A nurse manager is reviewing an incident report. Which statement is correct about incident
reports?
A. They should be placed in the client's medical record.
B. They document the facility's admission of liability.
C. They should be completed within 24 hours and not copied into the chart.
D. They are only completed when the client is injured.
C. They should be completed within 24 hours and not copied into the chart.
Incident reports are internal quality documents, completed promptly, and never filed in the
medical record (A). They do not constitute admission of liability (B) and are completed for near-
misses as well as injuries (D).
8. A nurse is caring for a client who is a Jehovah's Witness and refuses a blood transfusion.
The client's hemoglobin is 6.2 g/dL and the client is symptomatic. Which action should the
nurse take?
A. Administer the transfusion as prescribed
B. Respect the client's refusal and document the decision
C. Ask the family to convince the client
D. Obtain a court order for the transfusion
B. Respect the client's refusal and document the decision
A competent adult has the right to refuse treatment, including life-sustaining treatment.
Administering against the client's wishes (A) is battery; C violates autonomy; D applies only in
specific legal circumstances involving incompetence or minors.
9. A nurse is preparing to delegate vital sign measurement to a UAP for a client receiving a
blood transfusion. Which instruction is most important?
A. "Take vital signs every 15 minutes."
B. "Report any change in how the client looks or feels immediately."
C. "Use the automatic blood pressure machine."
D. "Document the vital signs in the flow sheet."
, B. "Report any change in how the client looks or feels immediately."
The critical safety element is early recognition of a transfusion reaction. While frequency (A)
matters, the RN must emphasize immediate reporting of subjective/objective changes; C and D
are technique/documentation, not the priority.
10. A nurse is reviewing a client's chart and notes the client has a "Do Not Resuscitate" order.
The client develops pulselessness and apnea. Which action should the nurse take?
A. Begin CPR immediately
B. Call a code and begin compressions
C. Withhold resuscitation and provide comfort measures
D. Ask the family what they want to do
C. Withhold resuscitation and provide comfort measures
A valid DNR order directs the team to withhold CPR. A and B violate the order; D delays
appropriate care — the order is already in place.
11. A nurse is assigned to care for a client who is on droplet precautions. Which action
indicates correct use of PPE?
A. Wearing a surgical mask when within 3 feet of the client
B. Wearing an N95 respirator at all times
C. Wearing a gown and gloves only when entering the room
D. Wearing a mask only when the client coughs
A. Wearing a surgical mask when within 3 feet of the client
Droplet precautions require a surgical mask within 3 feet (or per facility policy) plus
standard precautions. N95 (B) is for airborne precautions; C omits the mask; D is not standard
— mask use is required for all room entry per most policies.
12. A nurse is teaching a client about the purpose of a living will. Which statement by the
client indicates understanding?
A. "It lets my doctor decide my care."
B. "It states my wishes for end-of-life treatment."
C. "It transfers my assets to my family."
D. "It appoints someone to make all my decisions."
comprehensive assessment 2019 B
1. A charge nurse is making client assignments on a medical-surgical unit. Which client should
the nurse assign to the LPN/LVN?
A. A client 4 hours post-cardiac catheterization with a femoral sheath
B. A client requiring a blood transfusion for chronic anemia
C. A client with a stable sacral pressure injury requiring a dressing change
D. A client newly admitted with chest pain and an elevated troponin
C. A client with a stable sacral pressure injury requiring a dressing change
LPN/LVNs can perform stable, predictable tasks such as dressing changes on chronic
wounds. A (post-catheterization with sheath) and D (new admission with possible ACS) require
RN assessment and monitoring; B (blood transfusion) requires RN assessment for transfusion
reactions.
2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Ambulating a client 1 day post-op total hip arthroplasty
B. Obtaining a stool specimen from a client with diarrhea
C. Teaching a client how to use an incentive spirometer
D. Assessing a client's incision for signs of infection
B. Obtaining a stool specimen from a client with diarrhea
Collecting a specimen is a standard, non-assessment task within UAP scope. A requires
RN/LPN evaluation of fall risk and surgical precautions; C is teaching (RN only); D is assessment
(RN only).
3. A nurse is caring for a client who speaks limited English and needs to sign informed
consent. Which action should the nurse take?
A. Ask the client's adult child to interpret
B. Use the facility's trained medical interpreter
C. Have the client sign the English consent and explain later
D. Use a bilingual UAP to interpret
, B. Use the facility's trained medical interpreter
Federal law and best practice require trained medical interpreters for informed consent.
Family members (A) may filter information, create conflict of interest, and are not trained; C
invalidates informed consent; D exceeds UAP scope and training.
4. A nurse is reviewing advance directives with a newly admitted client. Which statement
indicates the client understands a durable power of attorney for health care?
A. "It tells my doctor what treatments I want."
B. "It names the person who can make decisions if I can't."
C. "It's the same as a do-not-resuscitate order."
D. "It only takes effect after I die."
B. "It names the person who can make decisions if I can't."
A durable power of attorney for health care designates a surrogate decision-maker. A
describes a living will; C confuses it with a DNR; D describes a will/executor, not a healthcare
proxy.
5. A nurse is prioritizing care for four clients. Which client should the nurse see first?
A. A client with COPD reporting a new productive cough
B. A client 2 days post-op reporting incisional pain 4/10
C. A client with diabetes requesting a snack
D. A client with a new onset of confusion and BP 88/54 mm Hg
D. A client with a new onset of confusion and BP 88/54 mm Hg
New confusion with hypotension suggests decreased perfusion (e.g., sepsis, hemorrhage) —
a life-threatening priority. A is important but stable; B and C are routine needs.
6. A nurse is preparing to discharge a client who will receive home IV antibiotics via a
peripherally inserted central catheter (PICC). Which referral is the priority?
A. Physical therapy
B. Home health nursing
C. Occupational therapy
D. Social work
B. Home health nursing
Home health nursing provides skilled assessment, catheter care, and IV antibiotic
,administration in the home. PT/OT address mobility/ADLs; social work addresses resources —
none manage the PICC or infusion.
7. A nurse manager is reviewing an incident report. Which statement is correct about incident
reports?
A. They should be placed in the client's medical record.
B. They document the facility's admission of liability.
C. They should be completed within 24 hours and not copied into the chart.
D. They are only completed when the client is injured.
C. They should be completed within 24 hours and not copied into the chart.
Incident reports are internal quality documents, completed promptly, and never filed in the
medical record (A). They do not constitute admission of liability (B) and are completed for near-
misses as well as injuries (D).
8. A nurse is caring for a client who is a Jehovah's Witness and refuses a blood transfusion.
The client's hemoglobin is 6.2 g/dL and the client is symptomatic. Which action should the
nurse take?
A. Administer the transfusion as prescribed
B. Respect the client's refusal and document the decision
C. Ask the family to convince the client
D. Obtain a court order for the transfusion
B. Respect the client's refusal and document the decision
A competent adult has the right to refuse treatment, including life-sustaining treatment.
Administering against the client's wishes (A) is battery; C violates autonomy; D applies only in
specific legal circumstances involving incompetence or minors.
9. A nurse is preparing to delegate vital sign measurement to a UAP for a client receiving a
blood transfusion. Which instruction is most important?
A. "Take vital signs every 15 minutes."
B. "Report any change in how the client looks or feels immediately."
C. "Use the automatic blood pressure machine."
D. "Document the vital signs in the flow sheet."
, B. "Report any change in how the client looks or feels immediately."
The critical safety element is early recognition of a transfusion reaction. While frequency (A)
matters, the RN must emphasize immediate reporting of subjective/objective changes; C and D
are technique/documentation, not the priority.
10. A nurse is reviewing a client's chart and notes the client has a "Do Not Resuscitate" order.
The client develops pulselessness and apnea. Which action should the nurse take?
A. Begin CPR immediately
B. Call a code and begin compressions
C. Withhold resuscitation and provide comfort measures
D. Ask the family what they want to do
C. Withhold resuscitation and provide comfort measures
A valid DNR order directs the team to withhold CPR. A and B violate the order; D delays
appropriate care — the order is already in place.
11. A nurse is assigned to care for a client who is on droplet precautions. Which action
indicates correct use of PPE?
A. Wearing a surgical mask when within 3 feet of the client
B. Wearing an N95 respirator at all times
C. Wearing a gown and gloves only when entering the room
D. Wearing a mask only when the client coughs
A. Wearing a surgical mask when within 3 feet of the client
Droplet precautions require a surgical mask within 3 feet (or per facility policy) plus
standard precautions. N95 (B) is for airborne precautions; C omits the mask; D is not standard
— mask use is required for all room entry per most policies.
12. A nurse is teaching a client about the purpose of a living will. Which statement by the
client indicates understanding?
A. "It lets my doctor decide my care."
B. "It states my wishes for end-of-life treatment."
C. "It transfers my assets to my family."
D. "It appoints someone to make all my decisions."
