RN ATI capstone proctored comprehensive
assessment 2019 A (ANSWERS)
SECTION I: FUNDAMENTALS OF NURSING (Questions 1–18)
1. A nurse is preparing to administer medication to a client. Which of the following identifiers
should the nurse use to verify the client's identity?
A. Room number
B. Medical record number
C. Client's full name and date of birth
D. Client's bed position
Correct Answer: C. Client's full name and date of birth
Rationale: The Joint Commission's National Patient Safety Goals require using at least two
client identifiers when administering medications, blood products, or performing procedures.
Acceptable identifiers include the client's full name, medical record number, date of birth, or
telephone number. The client's room number or bed position is never acceptable as an
identifier because clients may be moved to different rooms.
2. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the
following actions should the nurse take first?
A. Position the sterile drape leaving the perineum exposed
B. Apply sterile gloves
C. Cleanse the urinary meatus
D. Inflate the balloon with sterile water
Correct Answer: A. Position the sterile drape leaving the perineum exposed
Rationale: The first action when preparing for urinary catheter insertion is to position the
client and apply the sterile drape so the perineum is exposed. This establishes the sterile field
and allows for visualization of the meatus. Applying sterile gloves and cleansing the meatus
follow after the sterile field is established.
,3. A nurse is performing hand hygiene before client care. Which of the following actions
should the nurse take?
A. Use hot water to increase cleaning effectiveness
B. Rinse hands under warm running water
C. Apply soap after rinsing hands
D. Keep hands lower than elbows during rinsing
Correct Answer: B. Rinse hands under warm running water
Rationale: Warm water is recommended for hand hygiene because hot water can damage
the skin and increase the risk of dermatitis. The nurse should wet hands first, apply soap, lather
for at least 20 seconds, rinse thoroughly under warm running water, and dry with a paper towel.
Hands should be kept lower than the elbows to allow water to flow from clean to dirty areas.
4. A nurse is caring for a client who has a new colostomy. Which of the following is the
priority teaching?
A. Diet restrictions
B. Stoma care
C. Activity limits
D. Medication changes
Correct Answer: B. Stoma care
Rationale: Stoma care is the priority teaching because proper stoma care prevents infection
and skin breakdown, which are immediate physiological concerns. Diet restrictions, activity
limits, and medication changes are important but secondary to preventing infection and
maintaining skin integrity.
5. A nurse is preparing to extinguish a small fire in a client's room. Which of the following
actions should the nurse take when using a fire extinguisher?
A. Aim the nozzle at the top of the fire
B. Slide the pin on top of the fire extinguisher to allow for use
C. Spray in a sweeping motion from the bottom of the fire upward
D. Stand 10 feet away from the fire
Correct Answer: B. Slide the pin on top of the fire extinguisher to allow for use
, Rationale: The PASS acronym guides fire extinguisher use: Pull the pin (slide it out), Aim at
the base of the fire, Squeeze the handle, and Sweep from side to side. The pin must be removed
before the extinguisher can be operated. The nozzle should be aimed at the base of the fire, not
the top, and the nurse should stand approximately 6 to 8 feet away.
6. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of
the following actions should the nurse take when removing a tied surgical mask?
A. Remove the mask by securely holding the ties and moving it away from the face
B. Remove the mask by touching the front of the mask
C. Pull the mask downward by the bottom ties first
D. Remove gloves after removing the mask
Correct Answer: A. Remove the mask by securely holding the ties and moving it away
from the face
Rationale: When removing a mask, the nurse should untie the bottom ties first, then the
top ties, and remove the mask by holding only the ties. The front of the mask is contaminated
and should never be touched. Gloves should be removed before the mask to prevent
contaminating the face.
7. A nurse is performing perineal care for a male client who has a spinal cord injury. Which of
the following techniques should the nurse use?
A. Cleanse from the scrotum toward the urethral meatus
B. Discard the washcloth after cleansing the urethral meatus
C. Use the same washcloth for the entire perineal area
D. Cleanse from the anal area toward the urethral meatus
Correct Answer: B. Discard the washcloth after cleansing the urethral meatus
Rationale: The urethral meatus is considered the cleanest area of the perineum. After
cleansing the meatus, the washcloth becomes contaminated and should be discarded. Cleansing
should always proceed from the cleanest (urethral meatus) to the dirtiest (anal area) to prevent
introducing bacteria into the urinary tract.
, 8. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is
acetaminophen drops 80 mg/0.8 mL. How many mL should the nurse administer? Round to
the nearest tenth.
A. 1.0 mL
B. 1.2 mL
C. 1.5 mL
D. 2.0 mL
Correct Answer: B. 1.2 mL
Rationale: Use the ratio and proportion method: 80 mg / 0.8 mL = 120 mg / X mL. Cross-
multiply: 80X = 96. X = 96 ÷ 80 = 1.2 mL. The nurse should administer 1.2 mL.
9. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hours IV to a
client. The nurse should set the infusion pump to deliver how many mL per hour? Round to
the nearest whole number.
A. 100 mL/hr
B. 125 mL/hr
C. 150 mL/hr
D. 175 mL/hr
Correct Answer: B. 125 mL/hr
Rationale: To calculate the infusion rate: Total volume ÷ Total hours = 1,000 mL ÷ 8 hours =
125 mL/hr.
10. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The
drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min? Round to the nearest whole number.
A. 10 gtt/min
B. 13 gtt/min
C. 15 gtt/min
D. 18 gtt/min
Correct Answer: B. 13 gtt/min
assessment 2019 A (ANSWERS)
SECTION I: FUNDAMENTALS OF NURSING (Questions 1–18)
1. A nurse is preparing to administer medication to a client. Which of the following identifiers
should the nurse use to verify the client's identity?
A. Room number
B. Medical record number
C. Client's full name and date of birth
D. Client's bed position
Correct Answer: C. Client's full name and date of birth
Rationale: The Joint Commission's National Patient Safety Goals require using at least two
client identifiers when administering medications, blood products, or performing procedures.
Acceptable identifiers include the client's full name, medical record number, date of birth, or
telephone number. The client's room number or bed position is never acceptable as an
identifier because clients may be moved to different rooms.
2. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the
following actions should the nurse take first?
A. Position the sterile drape leaving the perineum exposed
B. Apply sterile gloves
C. Cleanse the urinary meatus
D. Inflate the balloon with sterile water
Correct Answer: A. Position the sterile drape leaving the perineum exposed
Rationale: The first action when preparing for urinary catheter insertion is to position the
client and apply the sterile drape so the perineum is exposed. This establishes the sterile field
and allows for visualization of the meatus. Applying sterile gloves and cleansing the meatus
follow after the sterile field is established.
,3. A nurse is performing hand hygiene before client care. Which of the following actions
should the nurse take?
A. Use hot water to increase cleaning effectiveness
B. Rinse hands under warm running water
C. Apply soap after rinsing hands
D. Keep hands lower than elbows during rinsing
Correct Answer: B. Rinse hands under warm running water
Rationale: Warm water is recommended for hand hygiene because hot water can damage
the skin and increase the risk of dermatitis. The nurse should wet hands first, apply soap, lather
for at least 20 seconds, rinse thoroughly under warm running water, and dry with a paper towel.
Hands should be kept lower than the elbows to allow water to flow from clean to dirty areas.
4. A nurse is caring for a client who has a new colostomy. Which of the following is the
priority teaching?
A. Diet restrictions
B. Stoma care
C. Activity limits
D. Medication changes
Correct Answer: B. Stoma care
Rationale: Stoma care is the priority teaching because proper stoma care prevents infection
and skin breakdown, which are immediate physiological concerns. Diet restrictions, activity
limits, and medication changes are important but secondary to preventing infection and
maintaining skin integrity.
5. A nurse is preparing to extinguish a small fire in a client's room. Which of the following
actions should the nurse take when using a fire extinguisher?
A. Aim the nozzle at the top of the fire
B. Slide the pin on top of the fire extinguisher to allow for use
C. Spray in a sweeping motion from the bottom of the fire upward
D. Stand 10 feet away from the fire
Correct Answer: B. Slide the pin on top of the fire extinguisher to allow for use
, Rationale: The PASS acronym guides fire extinguisher use: Pull the pin (slide it out), Aim at
the base of the fire, Squeeze the handle, and Sweep from side to side. The pin must be removed
before the extinguisher can be operated. The nozzle should be aimed at the base of the fire, not
the top, and the nurse should stand approximately 6 to 8 feet away.
6. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of
the following actions should the nurse take when removing a tied surgical mask?
A. Remove the mask by securely holding the ties and moving it away from the face
B. Remove the mask by touching the front of the mask
C. Pull the mask downward by the bottom ties first
D. Remove gloves after removing the mask
Correct Answer: A. Remove the mask by securely holding the ties and moving it away
from the face
Rationale: When removing a mask, the nurse should untie the bottom ties first, then the
top ties, and remove the mask by holding only the ties. The front of the mask is contaminated
and should never be touched. Gloves should be removed before the mask to prevent
contaminating the face.
7. A nurse is performing perineal care for a male client who has a spinal cord injury. Which of
the following techniques should the nurse use?
A. Cleanse from the scrotum toward the urethral meatus
B. Discard the washcloth after cleansing the urethral meatus
C. Use the same washcloth for the entire perineal area
D. Cleanse from the anal area toward the urethral meatus
Correct Answer: B. Discard the washcloth after cleansing the urethral meatus
Rationale: The urethral meatus is considered the cleanest area of the perineum. After
cleansing the meatus, the washcloth becomes contaminated and should be discarded. Cleansing
should always proceed from the cleanest (urethral meatus) to the dirtiest (anal area) to prevent
introducing bacteria into the urinary tract.
, 8. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is
acetaminophen drops 80 mg/0.8 mL. How many mL should the nurse administer? Round to
the nearest tenth.
A. 1.0 mL
B. 1.2 mL
C. 1.5 mL
D. 2.0 mL
Correct Answer: B. 1.2 mL
Rationale: Use the ratio and proportion method: 80 mg / 0.8 mL = 120 mg / X mL. Cross-
multiply: 80X = 96. X = 96 ÷ 80 = 1.2 mL. The nurse should administer 1.2 mL.
9. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hours IV to a
client. The nurse should set the infusion pump to deliver how many mL per hour? Round to
the nearest whole number.
A. 100 mL/hr
B. 125 mL/hr
C. 150 mL/hr
D. 175 mL/hr
Correct Answer: B. 125 mL/hr
Rationale: To calculate the infusion rate: Total volume ÷ Total hours = 1,000 mL ÷ 8 hours =
125 mL/hr.
10. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The
drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min? Round to the nearest whole number.
A. 10 gtt/min
B. 13 gtt/min
C. 15 gtt/min
D. 18 gtt/min
Correct Answer: B. 13 gtt/min
