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ATI CAPSTONE CONTENT REVIEW
ASSESSMENTS
Questions 1 - 200
Advanced / Hard / Mixed Difficulty
Comprehensive Nursing Review Covering Medical-Surgical, Mental Health,
Maternity, Pediatrics, Pharmacology, and Leadership
1. A nurse is caring for a client who is 2 hours postoperative following a total hip
arthroplasty. The client reports sudden shortness of breath and chest pain. The
nurse notes tachycardia and tachypnea. Which of the following actions should
the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Notify the healthcare provider
C. Apply a pulse oximeter
D. Place the client in a high-Fowler's position
Valid answer: A
Explanation: The client's symptoms are consistent with a pulmonary embolism.
The priority action is to administer oxygen to maintain oxygenation. While
notifying the provider, applying a pulse oximeter, and positioning the client are
important, they follow the initial step of supporting oxygenation.
2. A nurse is providing discharge teaching to a client who has a new prescription
for enoxaparin. Which of the following statements by the client indicates an
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understanding of the teaching?
A. "I will massage the injection site after administering the medication."
B. "I will expel the air bubble from the syringe before injecting."
C. "I will inject the medication into my abdomen."
D. "I will aspirate for blood return before injecting."
Valid answer: C
Explanation: Enoxaparin is a low-molecular-weight heparin administered
subcutaneously in the abdomen. The air bubble should not be expelled. Massaging
the site is contraindicated as it can cause bruising. Aspiration is not recommended
for subcutaneous injections of anticoagulants.
3. A nurse is assessing a client who has a history of heart failure. The client
reports a weight gain of 3 pounds in 2 days and swelling in the lower
extremities. Which of the following findings should the nurse anticipate?
A. Decreased heart rate
B. Increased blood pressure
C. Jugular vein distention
D. Decreased respiratory rate
Valid answer: C
Explanation: Weight gain and peripheral edema in a client with heart failure
indicate fluid volume overload. Jugular vein distention is a classic sign of increased
central venous pressure due to fluid overload. The nurse should expect
tachycardia, hypertension, and tachypnea as compensatory mechanisms, not
decreased heart rate or respiratory rate.
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4. A nurse is caring for a client who has a nasogastric tube and is receiving
continuous enteral feedings. The nurse notes that the client has developed
diarrhea. Which of the following actions should the nurse take?
A. Decrease the feeding rate
B. Change the feeding formula
C. Administer an antidiarrheal medication
D. Check the client's gastric residual volume
Valid answer: B
Explanation: Diarrhea during enteral feedings is often caused by the formula
itself, such as a hyperosmolar formula or lactose intolerance. Changing to a
different formula may resolve the issue. Decreasing the rate may help but does not
address the underlying cause. Antidiarrheals should not be the first intervention.
Checking gastric residual volume is for assessing gastric emptying, not diarrhea.
5. A nurse is providing teaching to a client who has a new prescription for an
ACE inhibitor. Which of the following adverse effects should the nurse instruct
the client to report immediately?
A. Dry cough
B. Dizziness
C. Angioedema
D. Hyperkalemia
Valid answer: C
Explanation: Angioedema is a serious, potentially life-threatening adverse effect
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of ACE inhibitors. The client should report any swelling of the face, lips, tongue, or
difficulty breathing immediately. Dry cough, dizziness, and hyperkalemia are also
side effects but are less emergent than angioedema.
6. A nurse is assessing a client who has a history of chronic kidney disease. The
client's laboratory results show a serum potassium level of 6.2 mEq/L. Which of
the following interventions should the nurse anticipate?
A. Administration of potassium supplements
B. Administration of sodium polystyrene sulfonate
C. Restriction of dietary sodium
D. Administration of IV fluids
Valid answer: B
Explanation: A serum potassium of 6.2 mEq/L is critically elevated
(hyperkalemia). Sodium polystyrene sulfonate (Kayexalate) is a cation-exchange
resin that binds potassium in the gastrointestinal tract and promotes its excretion.
Potassium supplements would worsen the condition. Sodium restriction is not the
primary intervention for acute hyperkalemia.
7. A nurse is caring for a client who is receiving a blood transfusion. The client
develops chills, fever, and lower back pain. Which of the following actions
should the nurse take first?
A. Stop the blood transfusion
B. Notify the healthcare provider
C. Administer an antihistamine
ATI CAPSTONE CONTENT REVIEW
ASSESSMENTS
Questions 1 - 200
Advanced / Hard / Mixed Difficulty
Comprehensive Nursing Review Covering Medical-Surgical, Mental Health,
Maternity, Pediatrics, Pharmacology, and Leadership
1. A nurse is caring for a client who is 2 hours postoperative following a total hip
arthroplasty. The client reports sudden shortness of breath and chest pain. The
nurse notes tachycardia and tachypnea. Which of the following actions should
the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Notify the healthcare provider
C. Apply a pulse oximeter
D. Place the client in a high-Fowler's position
Valid answer: A
Explanation: The client's symptoms are consistent with a pulmonary embolism.
The priority action is to administer oxygen to maintain oxygenation. While
notifying the provider, applying a pulse oximeter, and positioning the client are
important, they follow the initial step of supporting oxygenation.
2. A nurse is providing discharge teaching to a client who has a new prescription
for enoxaparin. Which of the following statements by the client indicates an
,2|Page
understanding of the teaching?
A. "I will massage the injection site after administering the medication."
B. "I will expel the air bubble from the syringe before injecting."
C. "I will inject the medication into my abdomen."
D. "I will aspirate for blood return before injecting."
Valid answer: C
Explanation: Enoxaparin is a low-molecular-weight heparin administered
subcutaneously in the abdomen. The air bubble should not be expelled. Massaging
the site is contraindicated as it can cause bruising. Aspiration is not recommended
for subcutaneous injections of anticoagulants.
3. A nurse is assessing a client who has a history of heart failure. The client
reports a weight gain of 3 pounds in 2 days and swelling in the lower
extremities. Which of the following findings should the nurse anticipate?
A. Decreased heart rate
B. Increased blood pressure
C. Jugular vein distention
D. Decreased respiratory rate
Valid answer: C
Explanation: Weight gain and peripheral edema in a client with heart failure
indicate fluid volume overload. Jugular vein distention is a classic sign of increased
central venous pressure due to fluid overload. The nurse should expect
tachycardia, hypertension, and tachypnea as compensatory mechanisms, not
decreased heart rate or respiratory rate.
,3|Page
4. A nurse is caring for a client who has a nasogastric tube and is receiving
continuous enteral feedings. The nurse notes that the client has developed
diarrhea. Which of the following actions should the nurse take?
A. Decrease the feeding rate
B. Change the feeding formula
C. Administer an antidiarrheal medication
D. Check the client's gastric residual volume
Valid answer: B
Explanation: Diarrhea during enteral feedings is often caused by the formula
itself, such as a hyperosmolar formula or lactose intolerance. Changing to a
different formula may resolve the issue. Decreasing the rate may help but does not
address the underlying cause. Antidiarrheals should not be the first intervention.
Checking gastric residual volume is for assessing gastric emptying, not diarrhea.
5. A nurse is providing teaching to a client who has a new prescription for an
ACE inhibitor. Which of the following adverse effects should the nurse instruct
the client to report immediately?
A. Dry cough
B. Dizziness
C. Angioedema
D. Hyperkalemia
Valid answer: C
Explanation: Angioedema is a serious, potentially life-threatening adverse effect
, 4|Page
of ACE inhibitors. The client should report any swelling of the face, lips, tongue, or
difficulty breathing immediately. Dry cough, dizziness, and hyperkalemia are also
side effects but are less emergent than angioedema.
6. A nurse is assessing a client who has a history of chronic kidney disease. The
client's laboratory results show a serum potassium level of 6.2 mEq/L. Which of
the following interventions should the nurse anticipate?
A. Administration of potassium supplements
B. Administration of sodium polystyrene sulfonate
C. Restriction of dietary sodium
D. Administration of IV fluids
Valid answer: B
Explanation: A serum potassium of 6.2 mEq/L is critically elevated
(hyperkalemia). Sodium polystyrene sulfonate (Kayexalate) is a cation-exchange
resin that binds potassium in the gastrointestinal tract and promotes its excretion.
Potassium supplements would worsen the condition. Sodium restriction is not the
primary intervention for acute hyperkalemia.
7. A nurse is caring for a client who is receiving a blood transfusion. The client
develops chills, fever, and lower back pain. Which of the following actions
should the nurse take first?
A. Stop the blood transfusion
B. Notify the healthcare provider
C. Administer an antihistamine
