ATI CAPSTONE FUNDAMENTALS COMPREHENSIVE NURSING
EXAM: 200 NCLEX-STYLE QUESTIONS COVERING
FUNDAMENTALS, MED-SURG, PHARMACOLOGY, AND CRITICAL
CARE (WITH RATIONALES)
1. A client with dysphagia is at risk for aspiration. Which of the
following interventions should be included in the plan of care?
A) Place the client in a supine position during meals.
B) Encourage the client to drink thin liquids to ease swallowing.
C) Have the client sit upright for 1 hour following meals.
D) Provide the client with a straw to facilitate drinking.
Correct Answer: C
Rationale: Keeping the client upright for at least 1 hour after
meals uses gravity to help prevent gastric contents from refluxing
and being aspirated into the lungs. Supine positioning (A)
increases aspiration risk. Thin liquids (B) are harder to control for a
client with dysphagia and increase aspiration risk. Straws (D) can
speed up liquid flow and cause choking or aspiration.
2. The nurse is assessing an IV infusion site. The client reports pain,
and the site is red and warm. What is the nurse's priority action?
A) Slow the infusion rate.
B) Apply a warm compress to the site.
C) Discontinue the infusion.
D) Elevate the client's arm.
Correct Answer: C
, Rationale: Pain, redness, and warmth at an IV site are classic signs
of phlebitis or infiltration. The priority is to discontinue the
infusion immediately to prevent further tissue damage or
complications. Slowing the rate (A) does not address the
underlying inflammation. Applying a warm compress (B) may be
indicated after removal but is not the priority. Elevating the arm
(D) is not the primary intervention for an inflamed IV site.
3. During a routine abdominal assessment, what action should the
nurse take regarding palpation and auscultation?
A) Perform palpation before auscultation to identify areas of
tenderness.
B) Perform auscultation before palpation to avoid altering bowel
sounds.
C) Perform palpation and auscultation simultaneously.
D) Perform palpation only after the client has eaten.
Correct Answer: B
Rationale: Auscultation should always be performed before
palpation during an abdominal assessment because palpation can
stimulate peristalsis and alter bowel sounds, leading to inaccurate
findings. Palpation before auscultation (A) would distort the
assessment. Performing them simultaneously (C) is not the correct
sequence. Palpation after meals (D) is not a standard guideline.
4. A nurse is preparing to administer an enteral feeding to a client
with a nasogastric tube. Which of the following actions is most
important to perform first?
A) Flush the tube with 30 mL of air.
B) Verify tube placement by checking the pH of gastric aspirate.
C) Warm the formula to body temperature.
, D) Elevate the head of the bed to 15 degrees.
Correct Answer: B
Rationale: Verification of tube placement is the most critical step
before any enteral feeding to prevent accidental administration
into the lungs. Flushing with air (A) is not a reliable method for
placement verification. Warming formula (C) is a comfort measure
but not the priority. Elevating the head of the bed to 15 degrees
(D) is insufficient; 30-45 degrees is recommended.
5. The nurse is assessing a client's peripheral IV site and notes
swelling and coolness around the insertion area. The infusion
rate has slowed. What is the most likely cause?
A) Phlebitis
B) Infiltration
C) Air embolism
D) Fluid overload
Correct Answer: B
Rationale: Swelling and coolness at the IV site, along with a
slowed infusion rate, are hallmark signs of infiltration, where fluid
leaks into the surrounding tissue. Phlebitis (A) typically presents
with redness, warmth, and pain. Air embolism (C) is a rare but
serious complication causing respiratory distress. Fluid overload
(D) would present with systemic symptoms like edema and
crackles, not local swelling.
6. A client is 2 days post-operative from an appendectomy. The
nurse auscultates the abdomen and notes absent bowel sounds
in all four quadrants. What is the nurse's priority action?
A) Document the finding as normal for this post-operative period.
B) Prepare to administer a laxative.
, C) Notify the healthcare provider immediately.
D) Increase the client's oral fluid intake.
Correct Answer: C
Rationale: Persistent absent bowel sounds post-operatively can
indicate an ileus or bowel obstruction, which requires immediate
medical evaluation. While bowel sounds may be temporarily
decreased after surgery, complete absence is not normal and
needs prompt attention. Documenting (A) without acting would
delay care. Administering a laxative (B) could be dangerous if an
obstruction is present. Increasing fluids (D) will not resolve the
underlying issue.
7. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A) Continuous bubbling in the water-seal chamber.
B) Intermittent bubbling in the water-seal chamber.
C) Tidaling in the water-seal chamber.
D) 50 mL of drainage in the collection chamber over 4 hours.
Correct Answer: A
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak in the system, which requires immediate
assessment and intervention to prevent a pneumothorax.
Intermittent bubbling (B) is normal and indicates air is being
expelled from the pleural space. Tidaling (C) is a normal
fluctuation with respiration. 50 mL of drainage over 4 hours (D) is
within an acceptable range.
8. A client with a history of heart failure is prescribed furosemide.
Which laboratory value should the nurse monitor most closely?
A) Serum sodium
EXAM: 200 NCLEX-STYLE QUESTIONS COVERING
FUNDAMENTALS, MED-SURG, PHARMACOLOGY, AND CRITICAL
CARE (WITH RATIONALES)
1. A client with dysphagia is at risk for aspiration. Which of the
following interventions should be included in the plan of care?
A) Place the client in a supine position during meals.
B) Encourage the client to drink thin liquids to ease swallowing.
C) Have the client sit upright for 1 hour following meals.
D) Provide the client with a straw to facilitate drinking.
Correct Answer: C
Rationale: Keeping the client upright for at least 1 hour after
meals uses gravity to help prevent gastric contents from refluxing
and being aspirated into the lungs. Supine positioning (A)
increases aspiration risk. Thin liquids (B) are harder to control for a
client with dysphagia and increase aspiration risk. Straws (D) can
speed up liquid flow and cause choking or aspiration.
2. The nurse is assessing an IV infusion site. The client reports pain,
and the site is red and warm. What is the nurse's priority action?
A) Slow the infusion rate.
B) Apply a warm compress to the site.
C) Discontinue the infusion.
D) Elevate the client's arm.
Correct Answer: C
, Rationale: Pain, redness, and warmth at an IV site are classic signs
of phlebitis or infiltration. The priority is to discontinue the
infusion immediately to prevent further tissue damage or
complications. Slowing the rate (A) does not address the
underlying inflammation. Applying a warm compress (B) may be
indicated after removal but is not the priority. Elevating the arm
(D) is not the primary intervention for an inflamed IV site.
3. During a routine abdominal assessment, what action should the
nurse take regarding palpation and auscultation?
A) Perform palpation before auscultation to identify areas of
tenderness.
B) Perform auscultation before palpation to avoid altering bowel
sounds.
C) Perform palpation and auscultation simultaneously.
D) Perform palpation only after the client has eaten.
Correct Answer: B
Rationale: Auscultation should always be performed before
palpation during an abdominal assessment because palpation can
stimulate peristalsis and alter bowel sounds, leading to inaccurate
findings. Palpation before auscultation (A) would distort the
assessment. Performing them simultaneously (C) is not the correct
sequence. Palpation after meals (D) is not a standard guideline.
4. A nurse is preparing to administer an enteral feeding to a client
with a nasogastric tube. Which of the following actions is most
important to perform first?
A) Flush the tube with 30 mL of air.
B) Verify tube placement by checking the pH of gastric aspirate.
C) Warm the formula to body temperature.
, D) Elevate the head of the bed to 15 degrees.
Correct Answer: B
Rationale: Verification of tube placement is the most critical step
before any enteral feeding to prevent accidental administration
into the lungs. Flushing with air (A) is not a reliable method for
placement verification. Warming formula (C) is a comfort measure
but not the priority. Elevating the head of the bed to 15 degrees
(D) is insufficient; 30-45 degrees is recommended.
5. The nurse is assessing a client's peripheral IV site and notes
swelling and coolness around the insertion area. The infusion
rate has slowed. What is the most likely cause?
A) Phlebitis
B) Infiltration
C) Air embolism
D) Fluid overload
Correct Answer: B
Rationale: Swelling and coolness at the IV site, along with a
slowed infusion rate, are hallmark signs of infiltration, where fluid
leaks into the surrounding tissue. Phlebitis (A) typically presents
with redness, warmth, and pain. Air embolism (C) is a rare but
serious complication causing respiratory distress. Fluid overload
(D) would present with systemic symptoms like edema and
crackles, not local swelling.
6. A client is 2 days post-operative from an appendectomy. The
nurse auscultates the abdomen and notes absent bowel sounds
in all four quadrants. What is the nurse's priority action?
A) Document the finding as normal for this post-operative period.
B) Prepare to administer a laxative.
, C) Notify the healthcare provider immediately.
D) Increase the client's oral fluid intake.
Correct Answer: C
Rationale: Persistent absent bowel sounds post-operatively can
indicate an ileus or bowel obstruction, which requires immediate
medical evaluation. While bowel sounds may be temporarily
decreased after surgery, complete absence is not normal and
needs prompt attention. Documenting (A) without acting would
delay care. Administering a laxative (B) could be dangerous if an
obstruction is present. Increasing fluids (D) will not resolve the
underlying issue.
7. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A) Continuous bubbling in the water-seal chamber.
B) Intermittent bubbling in the water-seal chamber.
C) Tidaling in the water-seal chamber.
D) 50 mL of drainage in the collection chamber over 4 hours.
Correct Answer: A
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak in the system, which requires immediate
assessment and intervention to prevent a pneumothorax.
Intermittent bubbling (B) is normal and indicates air is being
expelled from the pleural space. Tidaling (C) is a normal
fluctuation with respiration. 50 mL of drainage over 4 hours (D) is
within an acceptable range.
8. A client with a history of heart failure is prescribed furosemide.
Which laboratory value should the nurse monitor most closely?
A) Serum sodium
