RN ATI Capstone Proctored Comprehensive Assessment
Test Exam Study Guide & Practice Questions with
Rationales (2025–2026) | NCLEX-Style Review
1. A nurse is preparing to insert an indwelling urinary catheter. Which action best prevents
CAUTI?
A. Use sterile technique and secure the tubing below the bladder
B. Perform hand hygiene, use sterile technique, and maintain a closed drainage system
C. Irrigate the catheter every 8 hours
D. Change the drainage bag every 24 hours
Rationale: CAUTI prevention centers on aseptic insertion, a closed drainage system, and
keeping the bag below bladder level to prevent backflow. Routine irrigation and daily bag
changes increase infection risk. (A is partially correct but incomplete; B is the most
comprehensive.)
2. A client is on fall precautions. Which intervention is the priority?
A. Place the bed in the lowest position
B. Provide a bed alarm
C. Keep the call light and personal items within reach
D. Apply a gait belt
Rationale: The priority is ensuring the client can summon help and reach necessities
without getting up unassisted. All options are valid fall-prevention measures, but C directly
addresses the most common cause of falls—unassisted ambulation.
3. Which finding requires immediate nurse intervention?
A. Blood pressure 110/70
B. Heart rate 88
C. Sudden shortness of breath with crackles
D. Temperature 99.1°F (37.3°C)
Rationale: Sudden dyspnea with crackles suggests fluid overload or pulmonary edema—a
life-threatening emergency. The other values are within normal limits.
,4. SATA — Which are correct hand hygiene indications? (Select all that apply.)
A. Before touching a patient
B. After body fluid exposure risk
C. After touching patient surroundings
D. Only after using the restroom
E. Before a clean/aseptic procedure
Rationale: WHO's "5 Moments" include before touching a patient, before clean/aseptic
procedure, after body fluid exposure, after touching a patient, and after touching surroundings.
D is incorrect—hand hygiene is far more frequent.
5. A nurse is caring for a client with an airborne infection. Which PPE is required?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield
Rationale: Airborne precautions (TB, measles, varicella) require an N95 or higher respirator.
Surgical masks are for droplet precautions.
6. A pressure injury shows full-thickness loss with visible subcutaneous fat but no bone/tendon.
What stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Rationale: Stage 3 = full-thickness loss extending into subcutaneous tissue but not bone,
tendon, or muscle. Stage 4 involves exposed bone/tendon/muscle.
7. Which client is at highest risk for impaired skin integrity?
A. A 30-year-old with a fractured arm
B. A 78-year-old immobile client with incontinence
C. A 45-year-old post-op ambulatory client
D. A 22-year-old with a sprained ankle
, Rationale: Advanced age, immobility, and moisture from incontinence are the top risk
factors for pressure injuries (Braden scale).
8. A nurse is teaching a client about a low-sodium diet. Which statement indicates
understanding?
A. "I can use salt substitute freely."
B. "I'll read food labels and avoid canned soups."
C. "I'll add soy sauce for flavor."
D. "I can eat fast food if I skip fries."
Rationale: Canned soups are high in sodium. Salt substitutes contain potassium (risky with
renal issues), and soy sauce/fast food are high-sodium.
9. Which action demonstrates proper body mechanics?
A. Twisting at the waist while lifting
B. Bend at the knees, keep the load close, and tighten abdominal muscles
C. Lift with the back muscles
D. Reach overhead to lift
Rationale: Proper body mechanics: bend at knees, keep load close to center of gravity,
tighten core, avoid twisting.
10. SATA — Which are signs of dehydration? (Select all that apply.)
A. Poor skin turgor
B. Dry mucous membranes
C. Bounding pulse
D. Decreased urine output
E. Sunken eyes
Rationale: Dehydration causes poor turgor, dry mucous membranes, oliguria, and sunken
eyes. A bounding pulse suggests fluid overload.
11. A nurse is performing a sterile dressing change. Which action breaks sterility?
A. Opening the kit away from the body
B. Reaching over the sterile field with an ungloved hand
, C. Adding sterile supplies by dropping them in
D. Keeping the field above waist level
Rationale: Reaching over a sterile field contaminates it. Sterile fields must remain above
waist level and only sterile items may enter.
12. A client reports pain 8/10. What is the nurse's first action?
A. Administer the prescribed analgesic
B. Assess the pain (location, quality, duration)
C. Reposition the client
D. Document the pain
Rationale: Assessment precedes intervention. The nurse must fully assess pain before
medicating (though for severe pain, assessment can be brief and concurrent).
13. Which is the correct order for donning PPE?
A. Gloves, gown, mask, goggles
B. Gown, mask, goggles, gloves
C. Mask, gloves, gown, goggles
D. Goggles, gown, gloves, mask
Rationale: Donning order: gown → mask/respirator → goggles/face shield → gloves. Gloves
are last so they cover the gown cuffs.
14. A nurse notes a client's IV site is red, swollen, and painful. What should the nurse do first?
A. Flush the line
B. Stop the infusion and discontinue the IV
C. Apply warm compresses
D. Document and continue
Rationale: These are signs of phlebitis/infiltration. Stop the infusion immediately, remove
the catheter, and restart in another site.
15. Which statement about restraints is correct?
A. Restraints are a first-line intervention
Test Exam Study Guide & Practice Questions with
Rationales (2025–2026) | NCLEX-Style Review
1. A nurse is preparing to insert an indwelling urinary catheter. Which action best prevents
CAUTI?
A. Use sterile technique and secure the tubing below the bladder
B. Perform hand hygiene, use sterile technique, and maintain a closed drainage system
C. Irrigate the catheter every 8 hours
D. Change the drainage bag every 24 hours
Rationale: CAUTI prevention centers on aseptic insertion, a closed drainage system, and
keeping the bag below bladder level to prevent backflow. Routine irrigation and daily bag
changes increase infection risk. (A is partially correct but incomplete; B is the most
comprehensive.)
2. A client is on fall precautions. Which intervention is the priority?
A. Place the bed in the lowest position
B. Provide a bed alarm
C. Keep the call light and personal items within reach
D. Apply a gait belt
Rationale: The priority is ensuring the client can summon help and reach necessities
without getting up unassisted. All options are valid fall-prevention measures, but C directly
addresses the most common cause of falls—unassisted ambulation.
3. Which finding requires immediate nurse intervention?
A. Blood pressure 110/70
B. Heart rate 88
C. Sudden shortness of breath with crackles
D. Temperature 99.1°F (37.3°C)
Rationale: Sudden dyspnea with crackles suggests fluid overload or pulmonary edema—a
life-threatening emergency. The other values are within normal limits.
,4. SATA — Which are correct hand hygiene indications? (Select all that apply.)
A. Before touching a patient
B. After body fluid exposure risk
C. After touching patient surroundings
D. Only after using the restroom
E. Before a clean/aseptic procedure
Rationale: WHO's "5 Moments" include before touching a patient, before clean/aseptic
procedure, after body fluid exposure, after touching a patient, and after touching surroundings.
D is incorrect—hand hygiene is far more frequent.
5. A nurse is caring for a client with an airborne infection. Which PPE is required?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield
Rationale: Airborne precautions (TB, measles, varicella) require an N95 or higher respirator.
Surgical masks are for droplet precautions.
6. A pressure injury shows full-thickness loss with visible subcutaneous fat but no bone/tendon.
What stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Rationale: Stage 3 = full-thickness loss extending into subcutaneous tissue but not bone,
tendon, or muscle. Stage 4 involves exposed bone/tendon/muscle.
7. Which client is at highest risk for impaired skin integrity?
A. A 30-year-old with a fractured arm
B. A 78-year-old immobile client with incontinence
C. A 45-year-old post-op ambulatory client
D. A 22-year-old with a sprained ankle
, Rationale: Advanced age, immobility, and moisture from incontinence are the top risk
factors for pressure injuries (Braden scale).
8. A nurse is teaching a client about a low-sodium diet. Which statement indicates
understanding?
A. "I can use salt substitute freely."
B. "I'll read food labels and avoid canned soups."
C. "I'll add soy sauce for flavor."
D. "I can eat fast food if I skip fries."
Rationale: Canned soups are high in sodium. Salt substitutes contain potassium (risky with
renal issues), and soy sauce/fast food are high-sodium.
9. Which action demonstrates proper body mechanics?
A. Twisting at the waist while lifting
B. Bend at the knees, keep the load close, and tighten abdominal muscles
C. Lift with the back muscles
D. Reach overhead to lift
Rationale: Proper body mechanics: bend at knees, keep load close to center of gravity,
tighten core, avoid twisting.
10. SATA — Which are signs of dehydration? (Select all that apply.)
A. Poor skin turgor
B. Dry mucous membranes
C. Bounding pulse
D. Decreased urine output
E. Sunken eyes
Rationale: Dehydration causes poor turgor, dry mucous membranes, oliguria, and sunken
eyes. A bounding pulse suggests fluid overload.
11. A nurse is performing a sterile dressing change. Which action breaks sterility?
A. Opening the kit away from the body
B. Reaching over the sterile field with an ungloved hand
, C. Adding sterile supplies by dropping them in
D. Keeping the field above waist level
Rationale: Reaching over a sterile field contaminates it. Sterile fields must remain above
waist level and only sterile items may enter.
12. A client reports pain 8/10. What is the nurse's first action?
A. Administer the prescribed analgesic
B. Assess the pain (location, quality, duration)
C. Reposition the client
D. Document the pain
Rationale: Assessment precedes intervention. The nurse must fully assess pain before
medicating (though for severe pain, assessment can be brief and concurrent).
13. Which is the correct order for donning PPE?
A. Gloves, gown, mask, goggles
B. Gown, mask, goggles, gloves
C. Mask, gloves, gown, goggles
D. Goggles, gown, gloves, mask
Rationale: Donning order: gown → mask/respirator → goggles/face shield → gloves. Gloves
are last so they cover the gown cuffs.
14. A nurse notes a client's IV site is red, swollen, and painful. What should the nurse do first?
A. Flush the line
B. Stop the infusion and discontinue the IV
C. Apply warm compresses
D. Document and continue
Rationale: These are signs of phlebitis/infiltration. Stop the infusion immediately, remove
the catheter, and restart in another site.
15. Which statement about restraints is correct?
A. Restraints are a first-line intervention
