RN ATI Capstone Proctored
Comprehensive Assessment 2019 B:
200 Practice Questions with Answers
and Rationales
A nurse is caring for a client who has a new prescription for a mechanical
soft diet. Which of the following food items should the nurse remove from
the client's meal tray? Answer: Grilled chicken breast. Rationale: A
mechanical soft diet includes foods that are easy to chew and swallow.
Grilled chicken breast is a tough, fibrous meat that requires significant
chewing. It should be replaced with ground or finely chopped poultry.
A nurse is preparing to discharge a client who has a new colostomy. Which
of the following actions is the nurse's priority? Answer: Ensure the client
can demonstrate proper stoma care. Rationale: The priority is client self-
management. Before discharge, the nurse must ensure the client can
independently perform the necessary care to prevent complications like
skin breakdown or infection.
A nurse is admitting a client who has active tuberculosis. Which of the
following types of isolation precautions should the nurse
initiate? Answer: Airborne precautions. Rationale: Tuberculosis is
transmitted via airborne droplet nuclei. Airborne precautions require a
negative pressure room, an N95 respirator, and the client wearing a surgical
mask when leaving the room.
,A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to
delegate? Answer: Performing perineal care for a client. Rationale: Perineal
care is a standard hygiene task that falls within the AP's scope of practice
and does not require nursing judgment. The nurse is still responsible for the
overall assessment and evaluation.
A nurse is caring for a client who has a new prescription for a living will.
Which of the following actions should the nurse take? Answer: Provide the
client with information about how to formulate the
document. Rationale: The nurse's role is to provide information and
support. The client must initiate the process, and the document must be
witnessed and signed according to state law. The nurse does not witness
the document or make decisions for the client.
A nurse is preparing a client for a procedure and needs to obtain informed
consent. The client states, "I don't understand what the doctor is going to
do." Which of the following actions should the nurse take? Answer: Notify
the provider that the client has questions about the
procedure. Rationale: It is the provider's responsibility to explain the
procedure, risks, benefits, and alternatives. The nurse's role is to ensure the
client has the information to make a decision and to clarify information, but
not to provide the primary explanation for consent.
A nurse is caring for a group of clients on a medical-surgical unit. Which of
the following clients should the nurse assess first? Answer: A client who is 2
days post-operative and reports sudden shortness of
breath. Rationale: Sudden shortness of breath is a potential sign of a
pulmonary embolism, a life-threatening complication. This is the most
acute and unstable client.
,A nurse is planning care for a client who has a new tracheostomy. Which of
the following actions should the nurse include in the plan of
care? Answer: Keep a tracheostomy obturator at the
bedside. Rationale: The obturator is used to guide the tracheostomy tube
during reinsertion. It should be kept at the bedside at all times in case the
tube is dislodged or needs to be changed.
A nurse is witnessing a client sign an informed consent for a surgical
procedure. The client states, "I'm not really sure about this surgery." Which
of the following actions should the nurse take? Answer: Notify the provider
that the client has questions about the surgery. Rationale: The nurse's
signature on the consent form verifies that the client voluntarily signed the
document. If the client expresses doubt, the nurse must inform the provider
so they can address the client's concerns.
A nurse is planning to discharge a client who has a new prescription for
home oxygen therapy. Which of the following statements should the nurse
include in the discharge teaching? Answer: "Post a 'No Smoking' sign in
your home." Rationale: Oxygen supports combustion, making it a fire
hazard. Strict fire safety measures, including "No Smoking" signs, are
essential.
A nurse is preparing to transfer a client from the bed to a chair. Which of
the following actions is the priority? Answer: Assess the client's ability to
bear weight. Rationale: Before any transfer, the nurse must assess the
client's mobility, strength, and ability to assist. This assessment determines
the safest transfer method and equipment needed.
A client tells a nurse, "I don't want to take that medication." Which of the
following actions should the nurse take? Answer: Discuss the client's
concerns about the medication. Rationale: The nurse should first explore
the client's reason for refusal. Understanding the concern can lead to
, education, negotiation, or finding a solution. The nurse cannot force the
client to take the medication.
A nurse is caring for a client who is on fall precautions. Which of the
following interventions should the nurse implement? Answer: Keep the call
light within the client's reach. Rationale: This is a key fall prevention
strategy. It ensures the client can easily call for assistance when needed,
reducing the risk of falls from attempting to get up independently.
A nurse is receiving a telephone order from a provider. Which of the
following actions should the nurse take? Answer: Repeat the order back to
the provider to ensure accuracy. Rationale: This is a critical safety step in
the "read-back" process. Repeating the order minimizes the risk of
transcription errors and confirms the order is correct.
A nurse is caring for a client who has a prescription for a 24-hour urine
collection. Which of the following actions should the nurse
take? Answer: Instruct the client to void and discard that urine at the start
time. Rationale: The collection begins with an empty bladder. The client
should void and discard the first specimen, then collect all subsequent urine
for the next 24 hours.
A nurse is discharging a client who has a prescription for a new medication.
Which of the following actions is the priority? Answer: Teach the client
about the purpose, dosage, and side effects of the
medication. Rationale: Medication education is essential for client safety
and adherence. The client must understand what the medication is for, how
to take it, and what adverse effects to monitor.
A nurse is caring for a client who is post-operative and has a PCA pump.
The client's partner asks if they can press the button for the client. Which of
the following responses should the nurse make? Answer: "Only you should
press the button, as you are the best judge of your pain." Rationale: Only
Comprehensive Assessment 2019 B:
200 Practice Questions with Answers
and Rationales
A nurse is caring for a client who has a new prescription for a mechanical
soft diet. Which of the following food items should the nurse remove from
the client's meal tray? Answer: Grilled chicken breast. Rationale: A
mechanical soft diet includes foods that are easy to chew and swallow.
Grilled chicken breast is a tough, fibrous meat that requires significant
chewing. It should be replaced with ground or finely chopped poultry.
A nurse is preparing to discharge a client who has a new colostomy. Which
of the following actions is the nurse's priority? Answer: Ensure the client
can demonstrate proper stoma care. Rationale: The priority is client self-
management. Before discharge, the nurse must ensure the client can
independently perform the necessary care to prevent complications like
skin breakdown or infection.
A nurse is admitting a client who has active tuberculosis. Which of the
following types of isolation precautions should the nurse
initiate? Answer: Airborne precautions. Rationale: Tuberculosis is
transmitted via airborne droplet nuclei. Airborne precautions require a
negative pressure room, an N95 respirator, and the client wearing a surgical
mask when leaving the room.
,A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to
delegate? Answer: Performing perineal care for a client. Rationale: Perineal
care is a standard hygiene task that falls within the AP's scope of practice
and does not require nursing judgment. The nurse is still responsible for the
overall assessment and evaluation.
A nurse is caring for a client who has a new prescription for a living will.
Which of the following actions should the nurse take? Answer: Provide the
client with information about how to formulate the
document. Rationale: The nurse's role is to provide information and
support. The client must initiate the process, and the document must be
witnessed and signed according to state law. The nurse does not witness
the document or make decisions for the client.
A nurse is preparing a client for a procedure and needs to obtain informed
consent. The client states, "I don't understand what the doctor is going to
do." Which of the following actions should the nurse take? Answer: Notify
the provider that the client has questions about the
procedure. Rationale: It is the provider's responsibility to explain the
procedure, risks, benefits, and alternatives. The nurse's role is to ensure the
client has the information to make a decision and to clarify information, but
not to provide the primary explanation for consent.
A nurse is caring for a group of clients on a medical-surgical unit. Which of
the following clients should the nurse assess first? Answer: A client who is 2
days post-operative and reports sudden shortness of
breath. Rationale: Sudden shortness of breath is a potential sign of a
pulmonary embolism, a life-threatening complication. This is the most
acute and unstable client.
,A nurse is planning care for a client who has a new tracheostomy. Which of
the following actions should the nurse include in the plan of
care? Answer: Keep a tracheostomy obturator at the
bedside. Rationale: The obturator is used to guide the tracheostomy tube
during reinsertion. It should be kept at the bedside at all times in case the
tube is dislodged or needs to be changed.
A nurse is witnessing a client sign an informed consent for a surgical
procedure. The client states, "I'm not really sure about this surgery." Which
of the following actions should the nurse take? Answer: Notify the provider
that the client has questions about the surgery. Rationale: The nurse's
signature on the consent form verifies that the client voluntarily signed the
document. If the client expresses doubt, the nurse must inform the provider
so they can address the client's concerns.
A nurse is planning to discharge a client who has a new prescription for
home oxygen therapy. Which of the following statements should the nurse
include in the discharge teaching? Answer: "Post a 'No Smoking' sign in
your home." Rationale: Oxygen supports combustion, making it a fire
hazard. Strict fire safety measures, including "No Smoking" signs, are
essential.
A nurse is preparing to transfer a client from the bed to a chair. Which of
the following actions is the priority? Answer: Assess the client's ability to
bear weight. Rationale: Before any transfer, the nurse must assess the
client's mobility, strength, and ability to assist. This assessment determines
the safest transfer method and equipment needed.
A client tells a nurse, "I don't want to take that medication." Which of the
following actions should the nurse take? Answer: Discuss the client's
concerns about the medication. Rationale: The nurse should first explore
the client's reason for refusal. Understanding the concern can lead to
, education, negotiation, or finding a solution. The nurse cannot force the
client to take the medication.
A nurse is caring for a client who is on fall precautions. Which of the
following interventions should the nurse implement? Answer: Keep the call
light within the client's reach. Rationale: This is a key fall prevention
strategy. It ensures the client can easily call for assistance when needed,
reducing the risk of falls from attempting to get up independently.
A nurse is receiving a telephone order from a provider. Which of the
following actions should the nurse take? Answer: Repeat the order back to
the provider to ensure accuracy. Rationale: This is a critical safety step in
the "read-back" process. Repeating the order minimizes the risk of
transcription errors and confirms the order is correct.
A nurse is caring for a client who has a prescription for a 24-hour urine
collection. Which of the following actions should the nurse
take? Answer: Instruct the client to void and discard that urine at the start
time. Rationale: The collection begins with an empty bladder. The client
should void and discard the first specimen, then collect all subsequent urine
for the next 24 hours.
A nurse is discharging a client who has a prescription for a new medication.
Which of the following actions is the priority? Answer: Teach the client
about the purpose, dosage, and side effects of the
medication. Rationale: Medication education is essential for client safety
and adherence. The client must understand what the medication is for, how
to take it, and what adverse effects to monitor.
A nurse is caring for a client who is post-operative and has a PCA pump.
The client's partner asks if they can press the button for the client. Which of
the following responses should the nurse make? Answer: "Only you should
press the button, as you are the best judge of your pain." Rationale: Only
