Proctored Capstone(ATI)
Comprehensive Assessment A-2025
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?
I will avoid crushing this medication
I'll switch to a lactose-free formula Correct answer- I will avoid crushing this
medication
A nurse is assessing a client who is receiving enteral feeding via an NG tube.
The client has developed hyperosmolar dehydration. Which of the following
actions should the nurse take when administering the client's findings?
Empty your ostomy pouch when it is half full
Switch to a lactose-free formula. Correct answer- Switch to a lactose-free
formula.
A nurse is teaching the parents of a school-age child who has sickle cell
anemia about managing the disease at home which of the following
instructions should the nurse include?
Apply cold compresses too painful areas
I should boil tap water for 2 minutes and call it before I mix it with powdered
formula Correct answer- Apply cold compresses too painful areas
A nurse is teaching about Safe Handling of formula to a client who is
postpartum and chooses to bottle feed her newborn. Which of the following
statements by the client indicates an understanding of the teaching?
I should boil tap water for 2 minutes before I mix it with powdered formula
I should use sterile water when I mix it with powdered formula Correct
answer- I should boil tap water for 2 minutes before I mix it with powdered
formula
A nurse is assessing a child who is post-operative following a tonsillectomy.
Which of the following findings should the nurse identify as the priority?
During this test, I will punch a button if the baby moves
Frequent swallowing Correct answer- Frequent
swallowing
A nurse is teaching a client who is pregnant about non-stress testing. Which
of the following statements by the client indicates an understanding of the
teaching?
,During this test, I will punch a button if the baby moves
,During this test, I will punch a button if I feel stressed Correct answer-
During this test, I will punch a button if the baby moves
A nurse is monitoring a client who is receiving a transfusion of packed
RBC's. The client reports chills, headaches, low back pain, and a feeling of
tightness in his chest. The nurse should identify that the client has
developed which of the following types of transfusion reactions?
Pudendal nerve block
Acute hemolytic Correct answer- Acute hemolytic
A nurse is caring for a client who is in the latent phase of Labor and reports
severe back pain. The vaginal examination reveals that the cervix is dilated
two centimeters, 25% effaced and -2 station. Which of the following
interventions should the nurse implement?
You should wear a snug fitting bra continuously for 72 hours
Request the provider prescribe a pudendal nerve block Correct answer-
Request the provider prescribe a pudendal nerve block
A nurse is teaching about how to suppress lactation with a client who is
postpartum and bottle feeding her newborn. Which of the following
instructions should the nurse include in the teaching?
You should wear a snug fitting bra continuously for 72 hours
Room number Correct answer- You should wear a snug fitting bra
continuously for 72 hours
A nurse is preparing to administer medication to a client. What are the
following identifiers should the nurse use to identify the client?
Room number
MRN Correct answer- Room number
A nurse is caring for a client who is taking antihypertensive medication and
is moving from a supine to a seated position. Which of the following findings
should indicate to the nurse that the client is experiencing orthostatic
hypotension?
The clients systolic blood pressure decreases by 25 mmHg
The clients systolic blood pressure increases by 35 mmHg Correct answer-
The clients systolic blood pressure decreases by 25 mmHg
While a nurse is caring for a client who is receiving mechanical
ventilation via an endotracheal tube, the high-pressure alarm of the
ventilator sounds. Which of the following actions should the nurse
take?
Look for a block in the tubes cuff
, Look for a leak in the tubes cuff Correct answer- Look for a leak in the tubes
cuff
A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
Monitor Vital Signs every hour throughout the transfusion
Position the sterile drape leaving the perineum exposed Correct answer-
Position the sterile drape leaving the perineum exposed
A nurse is planning to administer packed RBC's to an older adult client who
has a low hemoglobin level. Which of the following actions should the nurse
plan to take?
Monitor Vital Signs every hour throughout the transfusion
Monitor RR every hour throughout the transfusion Correct answer- Monitor
Vital Signs every hour throughout the transfusion
A new nurse in an acute mental health facility is teaching a client about
potential adverse effects of transcranial magnetic stimulation. The nurse
tells the client that he might feel light-headed but that it should not affect
his memory. The nurse is demonstrating which of the following ethical
principles?
Beneficence
Restrictive Correct answer- Beneficence
A nurse is teaching a class about providing care within the legal scope of
practice to a group of nurses. The nurse should include that which of the
following procedures is outside the legal scope of practice for an RN?
Irrigation of the external ear canal
Irrigation of the inferior ear canal Correct answer- Irrigation of the external
ear canal
A nurse in an acute care facility is caring for a client who has anorexia
nervosa. During the first week of care, which of the following actions should
the nurse take?
Observe the client for 1 hour after meals
Observe the client for 6 hours after meals Correct answer- Observe the
client for 1 hour after meals
A nurse is planning care for a client who has sciatica and a prescription for a
transcutaneous electrical nerve stimulation (TENS) unit. Which of the
following referral should the nurse anticipate for the client?
Primary Care Provider
Physical therapist Correct answer- Physical therapist
Comprehensive Assessment A-2025
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?
I will avoid crushing this medication
I'll switch to a lactose-free formula Correct answer- I will avoid crushing this
medication
A nurse is assessing a client who is receiving enteral feeding via an NG tube.
The client has developed hyperosmolar dehydration. Which of the following
actions should the nurse take when administering the client's findings?
Empty your ostomy pouch when it is half full
Switch to a lactose-free formula. Correct answer- Switch to a lactose-free
formula.
A nurse is teaching the parents of a school-age child who has sickle cell
anemia about managing the disease at home which of the following
instructions should the nurse include?
Apply cold compresses too painful areas
I should boil tap water for 2 minutes and call it before I mix it with powdered
formula Correct answer- Apply cold compresses too painful areas
A nurse is teaching about Safe Handling of formula to a client who is
postpartum and chooses to bottle feed her newborn. Which of the following
statements by the client indicates an understanding of the teaching?
I should boil tap water for 2 minutes before I mix it with powdered formula
I should use sterile water when I mix it with powdered formula Correct
answer- I should boil tap water for 2 minutes before I mix it with powdered
formula
A nurse is assessing a child who is post-operative following a tonsillectomy.
Which of the following findings should the nurse identify as the priority?
During this test, I will punch a button if the baby moves
Frequent swallowing Correct answer- Frequent
swallowing
A nurse is teaching a client who is pregnant about non-stress testing. Which
of the following statements by the client indicates an understanding of the
teaching?
,During this test, I will punch a button if the baby moves
,During this test, I will punch a button if I feel stressed Correct answer-
During this test, I will punch a button if the baby moves
A nurse is monitoring a client who is receiving a transfusion of packed
RBC's. The client reports chills, headaches, low back pain, and a feeling of
tightness in his chest. The nurse should identify that the client has
developed which of the following types of transfusion reactions?
Pudendal nerve block
Acute hemolytic Correct answer- Acute hemolytic
A nurse is caring for a client who is in the latent phase of Labor and reports
severe back pain. The vaginal examination reveals that the cervix is dilated
two centimeters, 25% effaced and -2 station. Which of the following
interventions should the nurse implement?
You should wear a snug fitting bra continuously for 72 hours
Request the provider prescribe a pudendal nerve block Correct answer-
Request the provider prescribe a pudendal nerve block
A nurse is teaching about how to suppress lactation with a client who is
postpartum and bottle feeding her newborn. Which of the following
instructions should the nurse include in the teaching?
You should wear a snug fitting bra continuously for 72 hours
Room number Correct answer- You should wear a snug fitting bra
continuously for 72 hours
A nurse is preparing to administer medication to a client. What are the
following identifiers should the nurse use to identify the client?
Room number
MRN Correct answer- Room number
A nurse is caring for a client who is taking antihypertensive medication and
is moving from a supine to a seated position. Which of the following findings
should indicate to the nurse that the client is experiencing orthostatic
hypotension?
The clients systolic blood pressure decreases by 25 mmHg
The clients systolic blood pressure increases by 35 mmHg Correct answer-
The clients systolic blood pressure decreases by 25 mmHg
While a nurse is caring for a client who is receiving mechanical
ventilation via an endotracheal tube, the high-pressure alarm of the
ventilator sounds. Which of the following actions should the nurse
take?
Look for a block in the tubes cuff
, Look for a leak in the tubes cuff Correct answer- Look for a leak in the tubes
cuff
A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
Monitor Vital Signs every hour throughout the transfusion
Position the sterile drape leaving the perineum exposed Correct answer-
Position the sterile drape leaving the perineum exposed
A nurse is planning to administer packed RBC's to an older adult client who
has a low hemoglobin level. Which of the following actions should the nurse
plan to take?
Monitor Vital Signs every hour throughout the transfusion
Monitor RR every hour throughout the transfusion Correct answer- Monitor
Vital Signs every hour throughout the transfusion
A new nurse in an acute mental health facility is teaching a client about
potential adverse effects of transcranial magnetic stimulation. The nurse
tells the client that he might feel light-headed but that it should not affect
his memory. The nurse is demonstrating which of the following ethical
principles?
Beneficence
Restrictive Correct answer- Beneficence
A nurse is teaching a class about providing care within the legal scope of
practice to a group of nurses. The nurse should include that which of the
following procedures is outside the legal scope of practice for an RN?
Irrigation of the external ear canal
Irrigation of the inferior ear canal Correct answer- Irrigation of the external
ear canal
A nurse in an acute care facility is caring for a client who has anorexia
nervosa. During the first week of care, which of the following actions should
the nurse take?
Observe the client for 1 hour after meals
Observe the client for 6 hours after meals Correct answer- Observe the
client for 1 hour after meals
A nurse is planning care for a client who has sciatica and a prescription for a
transcutaneous electrical nerve stimulation (TENS) unit. Which of the
following referral should the nurse anticipate for the client?
Primary Care Provider
Physical therapist Correct answer- Physical therapist
