RN ATI Capstone Proctored Comprehensive
Assessment With Questions And Answers With
Detailed Rationale
## SECTION 1: MANAGEMENT OF CARE & LEADERSHIP (Questions 1-30)
**1. A charge nurse is assigning client care to a team of nurses. Which of the following
clients should the charge nurse assign to the most experienced nurse?**
A) A client who is 1 day postoperative following an appendectomy
B) A client who is receiving a continuous IV infusion of heparin
C) A client who requires a blood transfusion
D) A client who is 2 hours post-cardiac catheterization
**Answer: D**
**Rationale:** The client who is 2 hours post-cardiac catheterization requires close
monitoring for bleeding, hematoma, and vascular complications. The most experienced
nurse should care for the most unstable or high-risk client.
---
**2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks should the nurse delegate to the UAP?**
A) Administering a tube feeding
B) Obtaining a sterile urine specimen
C) Performing a fingerstick glucose test
D) Assessing a client's pain level
,**Answer: C**
**Rationale:** Performing a fingerstick glucose test is within the scope of practice for
UAP and is a task that can be delegated. UAP cannot perform sterile procedures,
administer medications or feedings, or conduct assessments.
---
**3. A nurse on a medical unit has received change-of-shift report. Which client should
the nurse assess FIRST?**
A) A client with COPD and oxygen saturation of 88% on room air
B) A client with chest pain who reports pain 4/10 and is waiting for an ECG
C) A client with abdominal pain and a temperature of 38.3°C (100.9°F)
D) A client with a leg fracture who is asking for pain medication
**Answer: A**
**Rationale:** The client with oxygen saturation of 88% is unstable and requires
immediate intervention. Oxygen saturation below 90% indicates significant respiratory
compromise and should be prioritized using the ABC (Airway, Breathing, Circulation)
framework.
---
**4. A charge nurse on a pediatric unit is making assignments for a float nurse from the
medical unit. Which of the following clients is appropriate to assign to the float nurse?**
A) A 10-year-old client who has pneumonia and is receiving respiratory treatments
B) A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
,C) An 8-month-old client who is scheduled for a surgical repair of a ventricular septal
defect tomorrow
D) A 14-year-old client who is scheduled for discharge today following placement of a
Harrington rod
**Answer: A**
**Rationale:** The float nurse from the medical unit is familiar with respiratory conditions
like pneumonia. The other options require specialized pediatric oncology, cardiac, or
orthopedic postoperative care beyond the float nurse's expertise.
---
**5. A nurse is caring for a client who has a living will. The client's family is demanding
that the nurse perform CPR if the client arrests. What is the nurse's best response?**
A) "I will call the hospital's ethics committee to override the living will"
B) "The living will is a legal document; I will follow the client's documented wishes"
C) "I will perform CPR to respect the family's wishes"
D) "The provider will make the final decision when the time comes"
**Answer: B**
**Rationale:** A living will is a legally binding advance directive. The nurse must follow
the client's documented wishes regarding end-of-life care. The family cannot override a
legally valid advance directive.
---
**6. A nurse is caring for a client who has fluid volume overload. Which of the following
tasks should the nurse delegate to an assistive personnel?**
, A) Measure the client's daily weight
B) Assess the client's lung sounds
C) Evaluate the client's intake and output
D) Administer IV diuretics
**Answer: A**
**Rationale:** Measuring daily weight is a task that can be delegated to assistive
personnel. Assessment, evaluation, and medication administration require licensed
nursing judgment and cannot be delegated.
---
**7. A nurse is preparing to administer insulin to a client via a pen device. Which of the
following actions should the nurse take?**
A) Hold the device with the needle pointing downward
B) Prime the device with 2 units of insulin before each injection
C) Shake the device vigorously before use
D) Store the device in the refrigerator after each use
**Answer: B**
**Rationale:** The pen device should be primed with 2 units of insulin before each
injection to ensure proper function and accurate dosing. The device should not be
shaken, and once in use, it can be stored at room temperature.
---
Assessment With Questions And Answers With
Detailed Rationale
## SECTION 1: MANAGEMENT OF CARE & LEADERSHIP (Questions 1-30)
**1. A charge nurse is assigning client care to a team of nurses. Which of the following
clients should the charge nurse assign to the most experienced nurse?**
A) A client who is 1 day postoperative following an appendectomy
B) A client who is receiving a continuous IV infusion of heparin
C) A client who requires a blood transfusion
D) A client who is 2 hours post-cardiac catheterization
**Answer: D**
**Rationale:** The client who is 2 hours post-cardiac catheterization requires close
monitoring for bleeding, hematoma, and vascular complications. The most experienced
nurse should care for the most unstable or high-risk client.
---
**2. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks should the nurse delegate to the UAP?**
A) Administering a tube feeding
B) Obtaining a sterile urine specimen
C) Performing a fingerstick glucose test
D) Assessing a client's pain level
,**Answer: C**
**Rationale:** Performing a fingerstick glucose test is within the scope of practice for
UAP and is a task that can be delegated. UAP cannot perform sterile procedures,
administer medications or feedings, or conduct assessments.
---
**3. A nurse on a medical unit has received change-of-shift report. Which client should
the nurse assess FIRST?**
A) A client with COPD and oxygen saturation of 88% on room air
B) A client with chest pain who reports pain 4/10 and is waiting for an ECG
C) A client with abdominal pain and a temperature of 38.3°C (100.9°F)
D) A client with a leg fracture who is asking for pain medication
**Answer: A**
**Rationale:** The client with oxygen saturation of 88% is unstable and requires
immediate intervention. Oxygen saturation below 90% indicates significant respiratory
compromise and should be prioritized using the ABC (Airway, Breathing, Circulation)
framework.
---
**4. A charge nurse on a pediatric unit is making assignments for a float nurse from the
medical unit. Which of the following clients is appropriate to assign to the float nurse?**
A) A 10-year-old client who has pneumonia and is receiving respiratory treatments
B) A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
,C) An 8-month-old client who is scheduled for a surgical repair of a ventricular septal
defect tomorrow
D) A 14-year-old client who is scheduled for discharge today following placement of a
Harrington rod
**Answer: A**
**Rationale:** The float nurse from the medical unit is familiar with respiratory conditions
like pneumonia. The other options require specialized pediatric oncology, cardiac, or
orthopedic postoperative care beyond the float nurse's expertise.
---
**5. A nurse is caring for a client who has a living will. The client's family is demanding
that the nurse perform CPR if the client arrests. What is the nurse's best response?**
A) "I will call the hospital's ethics committee to override the living will"
B) "The living will is a legal document; I will follow the client's documented wishes"
C) "I will perform CPR to respect the family's wishes"
D) "The provider will make the final decision when the time comes"
**Answer: B**
**Rationale:** A living will is a legally binding advance directive. The nurse must follow
the client's documented wishes regarding end-of-life care. The family cannot override a
legally valid advance directive.
---
**6. A nurse is caring for a client who has fluid volume overload. Which of the following
tasks should the nurse delegate to an assistive personnel?**
, A) Measure the client's daily weight
B) Assess the client's lung sounds
C) Evaluate the client's intake and output
D) Administer IV diuretics
**Answer: A**
**Rationale:** Measuring daily weight is a task that can be delegated to assistive
personnel. Assessment, evaluation, and medication administration require licensed
nursing judgment and cannot be delegated.
---
**7. A nurse is preparing to administer insulin to a client via a pen device. Which of the
following actions should the nurse take?**
A) Hold the device with the needle pointing downward
B) Prime the device with 2 units of insulin before each injection
C) Shake the device vigorously before use
D) Store the device in the refrigerator after each use
**Answer: B**
**Rationale:** The pen device should be primed with 2 units of insulin before each
injection to ensure proper function and accurate dosing. The device should not be
shaken, and once in use, it can be stored at room temperature.
---
