EXAM ACTUAL QUESTIONS AND
CORRECT VERRIFIED ANSWERS |A+
GRADE (MOST RECENT!!!)
ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT QUESTIONS
Heat/Cold Therapy Safety
Question: A nurse is caring for several prescribed heat/cold therapies. Which of the
following clients are at risk of injury from these therapies? Select all that apply.
A. An older adult client prescribed heat therapy for hip pain
B. A middle-aged adult client prescribed cold therapy for muscle spasms
C. A client with diabetes prescribed cold therapy for a fractured toe
D. A fair-skinned, school-age client prescribed heat therapy after a soccer injury
E. A cognitively impaired older adult prescribed alternating heat and cold therapy
Answer: A, C, D, and E
Rationale: The nurse should use extreme caution with clients who are very young, older
adults, fair-skinned, have impaired cognition, and have comorbidities because they are at
higher risk for fragile skin and injury from temperature extremes. A middle-aged adult with
muscle spasms is not at increased risk.
TPN Administration
Question: A nurse is preparing to administer total parenteral nutrition (TPN) to a client.
Which of the following findings indicates a need to obtain a new bag of TPN before
administering?
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,A. The TPN solution has an oily appearance and a layer of fat on top of the solution
B. The TPN solution contains added electrolytes, vitamins, and trace elements
C. The bag of TPN was prepared by the pharmacy 12 hours prior
D. The bag of TPN is labeled with the client's name, medical record number, and
prescription
Answer: A
Rationale: Before administration of TPN, the nurse should look for "cracking" of TPN
solution. This occurs if the calcium or phosphorus content is high or if poor-salt albumin is
added. A "cracked" TPN solution has an oily appearance or a layer of fat on top of the
solution and should not be used.
Living Wills
Question: What is the name of a legal document that instructs health care providers and
family members about what, if any, life-sustaining treatment an individual wants if at some
time the individual is unable to make decisions?
A. Do Not Resuscitate
B. Informed consent
C. Living will
D. Durable power of attorney for health care
Answer: C
Rationale: A living will is a legal document that specifically outlines a client's wishes
regarding life-sustaining treatment. A DNR order is written by the provider when the client
requests not to be resuscitated. Informed consent is consent to surgery or a procedure. A
durable power of attorney for health care designates another person to make health care
decisions when the client becomes unable to make decisions independently.
Restraint Use
Question: A nurse manager is providing staff education on the correct use of restraints.
Which of the following should be included in this education? Select all that apply.
A. Restraints should not interfere with treatment
B. Restraints should not be used because of short staffing
C. It is not necessary to document the behaviors making restraint necessary
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,D. Staff must document type and location of the restraint and time applied
E. Assess neurovascular and neurosensory status every 2 hours
Answer: A, B, D, and E
Rationale: Restraints should be applied as a last resort after other measures have been
used. Thorough and timely documentation needs to be completed when restraints are
applied, following protocol and policy. Neurovascular and neurosensory status should be
assessed every 2 hours, along with frequent check-ins to ensure safety and comfort.
Restraints should not be used as a way to contain the client when a unit is short-staffed.
Infiltration Management
Question: A nurse is caring for a client who identifies an infiltration at the IV catheter site.
Identify the order the nurse should perform the following actions.
Answer:
1. Stop the infusion
2. Remove the IV catheter
3. Apply a sterile dressing
4. Elevate the extremity
5. Apply warm or cold compresses
Rationale: The nurse should first stop the infusion to prevent further infiltration. Next,
remove the IV catheter and apply a sterile dressing. Then elevate the extremity and apply
warm or cold compresses according to agency policy.
Kübler-Ross Stages of Grieving
Question: A nurse in a dialysis center is caring for a client who has a new diagnosis of end-
stage kidney disease. The client states, "I decided to come today, but I am not sure if I will
need to come back again this week. I am feeling much better since my discharge from the
hospital and I think my kidneys are working again." The nurse should identify that this client
is demonstrating which Kübler-Ross stage of grieving?
A. Anger
B. Denial
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, C. Bargaining
D. Depression
Answer: B
Rationale: During the denial stage of Kübler-Ross' stages of grieving, the client acts as
though nothing has happened and might refuse to believe or understand that a loss has
occurred. The client's statement that his kidneys are working again despite a diagnosis of
end-stage kidney disease demonstrates denial.
Pressure Ulcer Staging
Question: The nurse should recognize which of the following findings is a manifestation of
a stage 3 pressure ulcer?
Answer: Necrotic subcutaneous tissue
Rationale: Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss
with necrotic subcutaneous tissue. A stage 1 ulcer has intact skin with nonblanchable
redness. A stage 2 ulcer involves partial-thickness skin loss involving the epidermis and
dermis.
Pitting Edema Documentation
Question: A nurse is assessing a client for pitting edema and notes an indentation of 6 mm
(0.25 in) at the point of pressure. Which of the following notations should the nurse use to
document the severity of the client's edema?
Answer: 3+
Rationale: The nurse should document pitting edema of 5 to 7 mm as 3+. This is a
significant degree of edema requiring monitoring and intervention.
Palliative Care Understanding
Question: A nurse is caring for a client who has cancer and is receiving palliative care.
Which of the following statements by the client indicates they understand this type of
treatment?
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