RN ATI capstone proctored comprehensive
assessment 2019 B | ATI Comprehensive
Practice Test B | A+
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with COPD reporting a headache
B. A client 2 days postoperative reporting calf pain and shortness of breath
C. A client with diabetes requesting a snack
D. A client with a cast reporting mild itching
B
Rationale: Calf pain with shortness of breath suggests DVT with possible pulmonary
embolism—a life-threatening emergency requiring immediate assessment. COPD headache may
indicate CO₂ retention but is less acute. The other clients have non-urgent needs .
2. A charge nurse is assigning rooms for four clients. Which client should be placed in a private
room?
A. A client with pneumonia
B. A client with MRSA
C. A client with a diabetic foot ulcer
D. A client with COPD
B
Rationale: MRSA requires contact isolation and a private room to prevent transmission.
Pneumonia may require droplet precautions, but MRSA contact isolation is the priority for
single-room assignment .
3. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Assessing a postoperative incision
B. Teaching a client how to use a walker
C. Obtaining a capillary blood glucose level
D. Evaluating a client's pain level
C
, Rationale: APs can perform capillary blood glucose testing. Assessment, teaching, and
evaluation require nursing judgment and fall outside the AP's scope .
4. A nurse is caring for a client who has a new prescription for total parenteral nutrition
through a central line. Which instruction should the nurse include?
A. "I will change your IV tubing once every 48 hours."
B. "Abdominal distention is an expected effect of this therapy."
C. "I will need to check your gastric residual before administering feedings."
D. "I will need to measure your weight daily."
D
Rationale: Daily weight measurement is necessary to monitor fluid status and avoid fluid
overload. TPN tubing is changed every 24 hours, abdominal distention is an adverse finding, and
gastric residuals are checked for NG tubes, not central lines .
5. A nurse is supervising a newly licensed nurse on a mental health unit. For which action
should the supervising nurse intervene?
A. Sets boundaries with a manipulative client
B. Documents client refusals of medication
C. Tells a client he will lose phone privileges if he does not take his medication
D. Uses therapeutic communication techniques
C
Rationale: Threatening to remove privileges as a consequence for refusing medication is
coercive, violates client autonomy, and damages the therapeutic relationship .
6. A competent adult client refuses a blood transfusion for religious reasons. Which actions
should the nurse take? (Select all that apply.)
A. Verify the client understands risks
B. Document the refusal
C. Administer the transfusion if Hgb is critical
D. Notify the provider
E. Ask the family to override the decision
A, B, D
, Rationale: Competent adults have autonomy. The nurse ensures informed refusal,
documents it, and notifies the provider. Administering against the client's wishes or asking
family to override violates the client's rights .
7. A nurse on a medical-surgical unit is delegating tasks to an LPN/LVN. Which task should the
nurse delegate?
A. Initial admission assessment of a patient with pneumonia
B. Teaching a diabetic patient how to self-administer insulin
C. Administration of a tube feeding to a patient with a gastrostomy tube
D. Evaluation of a patient's response to pain medication
C
Rationale: LPNs/LVNs can administer enteral feedings and perform stable, predictable tasks.
Initial assessments, teaching, and evaluation require RN-level critical thinking .
8. A nurse is caring for a client who had abdominal surgery 24 hours ago. Which action is the
priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing
D. Monitor the incision site for findings of infection
C
Rationale: Using the ABC approach, assisting with deep breathing and coughing reduces the
risk for postoperative pneumonia and is the priority .
9. A charge nurse notices a nurse frequently violates unit policies by taking extended breaks.
Which statement should the charge nurse make?
A. "You are always taking too many breaks."
B. "I would like to talk to you about unit policies regarding break time."
C. "If you don't stop, I will report you."
D. "Why do you keep taking extra time?"
B
Rationale: This statement addresses the conflict cooperatively and nonthreateningly,
focusing on the behavior rather than the person .
10. A nurse receives report on four clients. Which client should be assessed first?
, A. A client who has an ileal conduit and mucus in the pouch
B. A client who has an arteriovenous fistula that vibrates when palpated
C. A client who had a transurethral resection of the prostate with red-tinged urine
D. A client who has chronic kidney disease with cloudy dialysate outflow
D
Rationale: Cloudy dialysate outflow indicates peritonitis, a life-threatening complication
requiring immediate intervention. The other findings are expected or non-urgent .
11. A nurse is triaging clients after a mass casualty event. Which client should receive care first
using disaster triage?
A. Client with a tension pneumothorax
B. Client with an open femur fracture
C. Client with a sprained ankle
D. Client with a minor laceration
A
Rationale: Under disaster triage, life-threatening but survivable injuries are red
(immediate). Tension pneumothorax requires immediate decompression .
12. A nurse is caring for a client who has a spinal cord injury at T4 and reports a sudden,
severe headache. The client's blood pressure is 188/96 mm Hg. Which action should the nurse
take first?
A. Check the client's urinary catheter for kinks
B. Administer an antihypertensive medication
C. Place the client in a high-Fowler's position
D. Assess the client for fecal impaction
C
Rationale: The client is experiencing autonomic dysreflexia. The priority is to sit the client
upright to use orthostatic pressure to lower blood pressure before addressing the stimulus .
13. A nurse is planning to delegate client care tasks to an AP. Which task should the nurse plan
to delegate?
A. Perform gastrostomy feedings through a client's established gastrostomy tube
B. Determine if the PRN pain medication administered 30 min ago has helped
C. Provide instructions about client care to a family member over the telephone
D. Teach a client how to measure their own blood pressure
assessment 2019 B | ATI Comprehensive
Practice Test B | A+
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with COPD reporting a headache
B. A client 2 days postoperative reporting calf pain and shortness of breath
C. A client with diabetes requesting a snack
D. A client with a cast reporting mild itching
B
Rationale: Calf pain with shortness of breath suggests DVT with possible pulmonary
embolism—a life-threatening emergency requiring immediate assessment. COPD headache may
indicate CO₂ retention but is less acute. The other clients have non-urgent needs .
2. A charge nurse is assigning rooms for four clients. Which client should be placed in a private
room?
A. A client with pneumonia
B. A client with MRSA
C. A client with a diabetic foot ulcer
D. A client with COPD
B
Rationale: MRSA requires contact isolation and a private room to prevent transmission.
Pneumonia may require droplet precautions, but MRSA contact isolation is the priority for
single-room assignment .
3. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Assessing a postoperative incision
B. Teaching a client how to use a walker
C. Obtaining a capillary blood glucose level
D. Evaluating a client's pain level
C
, Rationale: APs can perform capillary blood glucose testing. Assessment, teaching, and
evaluation require nursing judgment and fall outside the AP's scope .
4. A nurse is caring for a client who has a new prescription for total parenteral nutrition
through a central line. Which instruction should the nurse include?
A. "I will change your IV tubing once every 48 hours."
B. "Abdominal distention is an expected effect of this therapy."
C. "I will need to check your gastric residual before administering feedings."
D. "I will need to measure your weight daily."
D
Rationale: Daily weight measurement is necessary to monitor fluid status and avoid fluid
overload. TPN tubing is changed every 24 hours, abdominal distention is an adverse finding, and
gastric residuals are checked for NG tubes, not central lines .
5. A nurse is supervising a newly licensed nurse on a mental health unit. For which action
should the supervising nurse intervene?
A. Sets boundaries with a manipulative client
B. Documents client refusals of medication
C. Tells a client he will lose phone privileges if he does not take his medication
D. Uses therapeutic communication techniques
C
Rationale: Threatening to remove privileges as a consequence for refusing medication is
coercive, violates client autonomy, and damages the therapeutic relationship .
6. A competent adult client refuses a blood transfusion for religious reasons. Which actions
should the nurse take? (Select all that apply.)
A. Verify the client understands risks
B. Document the refusal
C. Administer the transfusion if Hgb is critical
D. Notify the provider
E. Ask the family to override the decision
A, B, D
, Rationale: Competent adults have autonomy. The nurse ensures informed refusal,
documents it, and notifies the provider. Administering against the client's wishes or asking
family to override violates the client's rights .
7. A nurse on a medical-surgical unit is delegating tasks to an LPN/LVN. Which task should the
nurse delegate?
A. Initial admission assessment of a patient with pneumonia
B. Teaching a diabetic patient how to self-administer insulin
C. Administration of a tube feeding to a patient with a gastrostomy tube
D. Evaluation of a patient's response to pain medication
C
Rationale: LPNs/LVNs can administer enteral feedings and perform stable, predictable tasks.
Initial assessments, teaching, and evaluation require RN-level critical thinking .
8. A nurse is caring for a client who had abdominal surgery 24 hours ago. Which action is the
priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing
D. Monitor the incision site for findings of infection
C
Rationale: Using the ABC approach, assisting with deep breathing and coughing reduces the
risk for postoperative pneumonia and is the priority .
9. A charge nurse notices a nurse frequently violates unit policies by taking extended breaks.
Which statement should the charge nurse make?
A. "You are always taking too many breaks."
B. "I would like to talk to you about unit policies regarding break time."
C. "If you don't stop, I will report you."
D. "Why do you keep taking extra time?"
B
Rationale: This statement addresses the conflict cooperatively and nonthreateningly,
focusing on the behavior rather than the person .
10. A nurse receives report on four clients. Which client should be assessed first?
, A. A client who has an ileal conduit and mucus in the pouch
B. A client who has an arteriovenous fistula that vibrates when palpated
C. A client who had a transurethral resection of the prostate with red-tinged urine
D. A client who has chronic kidney disease with cloudy dialysate outflow
D
Rationale: Cloudy dialysate outflow indicates peritonitis, a life-threatening complication
requiring immediate intervention. The other findings are expected or non-urgent .
11. A nurse is triaging clients after a mass casualty event. Which client should receive care first
using disaster triage?
A. Client with a tension pneumothorax
B. Client with an open femur fracture
C. Client with a sprained ankle
D. Client with a minor laceration
A
Rationale: Under disaster triage, life-threatening but survivable injuries are red
(immediate). Tension pneumothorax requires immediate decompression .
12. A nurse is caring for a client who has a spinal cord injury at T4 and reports a sudden,
severe headache. The client's blood pressure is 188/96 mm Hg. Which action should the nurse
take first?
A. Check the client's urinary catheter for kinks
B. Administer an antihypertensive medication
C. Place the client in a high-Fowler's position
D. Assess the client for fecal impaction
C
Rationale: The client is experiencing autonomic dysreflexia. The priority is to sit the client
upright to use orthostatic pressure to lower blood pressure before addressing the stimulus .
13. A nurse is planning to delegate client care tasks to an AP. Which task should the nurse plan
to delegate?
A. Perform gastrostomy feedings through a client's established gastrostomy tube
B. Determine if the PRN pain medication administered 30 min ago has helped
C. Provide instructions about client care to a family member over the telephone
D. Teach a client how to measure their own blood pressure
