ATI Capstone Comprehensive
Assessment A Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A client with COPD is receiving oxygen therapy. What is the nurse's priority action when the
client reports increased shortness of breath while on 4 L/min via nasal cannula?
✔✔ Reduce oxygen to 2 L/min and reassess the client’s respiratory rate and effort.
A nurse is caring for a client who has heart failure and gained 2 kg in 24 hours. What is the
appropriate nursing action?
✔✔ Notify the provider of possible fluid overload.
A client with a deep partial-thickness burn is receiving IV fluids. Which finding indicates that
fluid resuscitation is effective?
✔✔ Urine output of 50 mL/hr.
A nurse is preparing to administer a blood transfusion. What should the nurse do immediately
before initiating the transfusion?
✔✔ Verify the client’s identification with another licensed nurse.
1
,A client is prescribed digoxin. The nurse assesses a heart rate of 52 bpm. What is the appropriate
action?
✔✔ Withhold the medication and notify the provider.
A nurse is reinforcing teaching about insulin administration. What instruction should the nurse
include?
✔✔ Rotate injection sites to prevent lipodystrophy.
A client who is postoperative reports sudden chest pain and shortness of breath. What is the
nurse’s priority action?
✔✔ Apply oxygen via non-rebreather mask.
A client with diabetes has a blood glucose level of 42 mg/dL. What is the nurse’s priority action?
✔✔ Administer 15 grams of fast-acting carbohydrate.
A nurse is providing care to a client with a new tracheostomy. What is the priority nursing
intervention?
✔✔ Maintain a patent airway.
2
,A client is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse
monitor closely?
✔✔ Blood glucose level.
A nurse is caring for a client with tuberculosis. What type of isolation is required?
✔✔ Airborne precautions.
A client who is postoperative is at risk for hypovolemia. What assessment finding should the
nurse report immediately?
✔✔ Systolic blood pressure of 82 mm Hg.
A client receiving chemotherapy reports mouth sores and pain when eating. What is the nurse’s
best recommendation?
✔✔ Rinse the mouth with a saline solution before and after meals.
A client is on a low-sodium diet. Which food should the nurse instruct the client to avoid?
✔✔ Canned soup.
3
, A nurse is reviewing medication administration for a client receiving heparin. What lab value
should the nurse monitor?
✔✔ aPTT.
A client is scheduled for a lumbar puncture. What is the correct position during the procedure?
✔✔ Side-lying with knees drawn to the chest.
A nurse is reviewing discharge instructions with a client who has a new prescription for
furosemide. What should the nurse include?
✔✔ Eat foods high in potassium.
A client reports severe lower abdominal pain and dizziness. The nurse notes a positive pregnancy
test. What condition should be suspected?
✔✔ Ectopic pregnancy.
A client is prescribed a new antibiotic and develops wheezing and facial swelling. What is the
nurse’s priority?
✔✔ Stop the antibiotic and initiate emergency care.
4
Assessment A Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A client with COPD is receiving oxygen therapy. What is the nurse's priority action when the
client reports increased shortness of breath while on 4 L/min via nasal cannula?
✔✔ Reduce oxygen to 2 L/min and reassess the client’s respiratory rate and effort.
A nurse is caring for a client who has heart failure and gained 2 kg in 24 hours. What is the
appropriate nursing action?
✔✔ Notify the provider of possible fluid overload.
A client with a deep partial-thickness burn is receiving IV fluids. Which finding indicates that
fluid resuscitation is effective?
✔✔ Urine output of 50 mL/hr.
A nurse is preparing to administer a blood transfusion. What should the nurse do immediately
before initiating the transfusion?
✔✔ Verify the client’s identification with another licensed nurse.
1
,A client is prescribed digoxin. The nurse assesses a heart rate of 52 bpm. What is the appropriate
action?
✔✔ Withhold the medication and notify the provider.
A nurse is reinforcing teaching about insulin administration. What instruction should the nurse
include?
✔✔ Rotate injection sites to prevent lipodystrophy.
A client who is postoperative reports sudden chest pain and shortness of breath. What is the
nurse’s priority action?
✔✔ Apply oxygen via non-rebreather mask.
A client with diabetes has a blood glucose level of 42 mg/dL. What is the nurse’s priority action?
✔✔ Administer 15 grams of fast-acting carbohydrate.
A nurse is providing care to a client with a new tracheostomy. What is the priority nursing
intervention?
✔✔ Maintain a patent airway.
2
,A client is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse
monitor closely?
✔✔ Blood glucose level.
A nurse is caring for a client with tuberculosis. What type of isolation is required?
✔✔ Airborne precautions.
A client who is postoperative is at risk for hypovolemia. What assessment finding should the
nurse report immediately?
✔✔ Systolic blood pressure of 82 mm Hg.
A client receiving chemotherapy reports mouth sores and pain when eating. What is the nurse’s
best recommendation?
✔✔ Rinse the mouth with a saline solution before and after meals.
A client is on a low-sodium diet. Which food should the nurse instruct the client to avoid?
✔✔ Canned soup.
3
, A nurse is reviewing medication administration for a client receiving heparin. What lab value
should the nurse monitor?
✔✔ aPTT.
A client is scheduled for a lumbar puncture. What is the correct position during the procedure?
✔✔ Side-lying with knees drawn to the chest.
A nurse is reviewing discharge instructions with a client who has a new prescription for
furosemide. What should the nurse include?
✔✔ Eat foods high in potassium.
A client reports severe lower abdominal pain and dizziness. The nurse notes a positive pregnancy
test. What condition should be suspected?
✔✔ Ectopic pregnancy.
A client is prescribed a new antibiotic and develops wheezing and facial swelling. What is the
nurse’s priority?
✔✔ Stop the antibiotic and initiate emergency care.
4
