RN ATI Capstone Proctored Comprehensive
Assessment 2019 B (150 Q and A) | Answers
Section 1: Management of Care (Questions 1–22)
1. A nurse is prioritizing care for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client requesting pain medication for chronic back pain rated 6/10
B. A client who had abdominal surgery 24 hours ago and now has a respiratory rate of 28/min
and shallow breathing
C. A client awaiting discharge teaching about warfarin therapy
D. A client with a blood glucose level of 180 mg/dL who is scheduled for lunch
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the client with
shallow respirations at 28/min post-abdominal surgery is at risk for atelectasis and respiratory
compromise. This finding requires immediate assessment and intervention. Pain management,
discharge teaching, and an elevated blood glucose before a meal are important but not
immediately life-threatening.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks
should the nurse delegate?
A. Assessing a client's IV site for phlebitis
B. Administering a gastrostomy tube feeding through an established tube
C. Teaching a client how to self-administer insulin
D. Evaluating a client's response to a PRN analgesic
Correct Answer: B
Rationale: Performing a gastrostomy tube feeding through an established tube is within the
AP's scope of function. Assessment, evaluation, and teaching are RN responsibilities that cannot
be delegated to assistive personnel.
3. A nurse is resolving a conflict between two staff nurses regarding client assignment. Which
of the following approaches should the nurse manager take first?
A. Reassign both nurses to different units
B. Facilitate a private discussion between the two nurses
,C. Discipline both nurses for unprofessional behavior
D. Ignore the conflict and allow it to resolve naturally
Correct Answer: B
Rationale: The best approach to conflict resolution begins with facilitating open
communication between the involved parties in a private setting. This promotes collaboration
and allows each nurse to express concerns. Reassignment, discipline, and ignoring the conflict
do not address the underlying issue.
4. A nurse is caring for a client who speaks a language different from the nurse's. Which of the
following actions should the nurse take?
A. Ask the client's family member to interpret
B. Request an interpreter of the same sex as the client when possible
C. Speak slowly and loudly while using gestures
D. Provide written instructions in English
Correct Answer: B
Rationale: When caring for a client with limited English proficiency, the nurse should use a
professional medical interpreter, preferably one of the same sex if the client prefers. Family
members should not be used as interpreters due to potential for errors and confidentiality
concerns. Speaking loudly does not improve comprehension.
5. A nurse is reviewing advance directives with a middle adult client. Which of the following
statements by the client indicates understanding?
A. "I can designate my partner as my health care surrogate."
B. "My family can override my living will if they disagree."
C. "Advance directives only apply when I am terminally ill."
D. "I need a lawyer to create a living will."
Correct Answer: A
Rationale: Designating a health care surrogate is a component of advance directives. The
client can appoint someone to make healthcare decisions if they become unable to do so.
Advance directives apply in various situations beyond terminal illness, and a lawyer is not
required.
6. A nurse is preparing to transfer a client from the ICU to the medical floor. Which of the
following information should the nurse include in the change-of-shift report?
,A. The client's admission date and medical record number
B. The time of the client's last dose of pain medication
C. The client's preferred television channel
D. The names of all family members who have visited
Correct Answer: B
Rationale: An effective handoff report includes recent changes and priority situations
affecting the client's condition. The time of the last pain medication dose is essential for the
receiving nurse to anticipate the next dose. Administrative details and preferences are less
critical.
7. A nurse is reviewing a newly licensed nurse's documentation. Which of the following
notations indicates correct documentation?
A. "OOB with assistance for breakfast"
B. "Given 2 mg MSO4 IM for report of pain"
C. "Dressing changed qd"
D. "Administered 8 u regular insulin sq."
Correct Answer: A
Rationale: "OOB with assistance for breakfast" uses approved abbreviations and clearly
describes the activity. "MSO4" can be confused with magnesium sulfate, "qd" is on the Do Not
Use list (use "daily"), and "u" should be written as "units."
8. A nurse is planning care for a client who has a new prescription for a low-sodium diet.
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh apples
B. Canned soup
C. Grilled chicken breast
D. Steamed broccoli
Correct Answer: B
Rationale: Canned soups are high in sodium due to added salt as a preservative. Fresh
fruits, unprocessed meats, and fresh vegetables are naturally low in sodium.
9. A nurse is assessing a client's ability to sign informed consent. Which of the following
findings indicates the client is capable of providing consent?
A. The client is able to accurately describe the upcoming procedure.
B. The client asks the nurse what procedure is scheduled.
, C. The client's family member is present and agrees with the procedure.
D. The client has a temperature of 38.2°C (100.8°F).
Correct Answer: A
Rationale: For informed consent to be valid, the client must understand the procedure, its
risks, and benefits. The ability to accurately describe the procedure indicates comprehension.
Family presence, fever, or lack of knowledge do not indicate capacity.
10. A nurse manager is planning to use a democratic leadership style. Which of the following
actions demonstrates this style?
A. Making decisions independently and informing staff afterward
B. Seeking input from staff nurses before making decisions
C. Allowing staff to set their own schedules without guidelines
D. Delegating all management tasks to the charge nurse
Correct Answer: B
Rationale: Democratic leadership involves including team members in decision-making and
encouraging staff participation. This differs from autocratic (independent decisions) or laissez-
faire (no guidance) styles.
11. A nurse is caring for a client who has a history of falls. Which of the following
interventions should the nurse include in the plan of care?
A. Apply a yellow wristband to identify fall risk.
B. Keep the bed in the highest position.
C. Use a chair alarm only for confused clients.
D. Restrict all client activity to prevent falls.
Correct Answer: A
Rationale: Yellow wristbands are standard for identifying fall risk clients. The bed should be
kept in the lowest position, alarms should be used for at-risk clients regardless of confusion, and
activity should not be restricted as this leads to deconditioning.
12. A nurse is preparing to administer a blood transfusion. Which of the following actions
should the nurse take first?
A. Verify the client's identity with a second nurse.
B. Obtain the client's vital signs.
C. Explain the procedure to the client.
D. Prime the IV tubing with 0.9% sodium chloride.
Assessment 2019 B (150 Q and A) | Answers
Section 1: Management of Care (Questions 1–22)
1. A nurse is prioritizing care for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client requesting pain medication for chronic back pain rated 6/10
B. A client who had abdominal surgery 24 hours ago and now has a respiratory rate of 28/min
and shallow breathing
C. A client awaiting discharge teaching about warfarin therapy
D. A client with a blood glucose level of 180 mg/dL who is scheduled for lunch
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the client with
shallow respirations at 28/min post-abdominal surgery is at risk for atelectasis and respiratory
compromise. This finding requires immediate assessment and intervention. Pain management,
discharge teaching, and an elevated blood glucose before a meal are important but not
immediately life-threatening.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks
should the nurse delegate?
A. Assessing a client's IV site for phlebitis
B. Administering a gastrostomy tube feeding through an established tube
C. Teaching a client how to self-administer insulin
D. Evaluating a client's response to a PRN analgesic
Correct Answer: B
Rationale: Performing a gastrostomy tube feeding through an established tube is within the
AP's scope of function. Assessment, evaluation, and teaching are RN responsibilities that cannot
be delegated to assistive personnel.
3. A nurse is resolving a conflict between two staff nurses regarding client assignment. Which
of the following approaches should the nurse manager take first?
A. Reassign both nurses to different units
B. Facilitate a private discussion between the two nurses
,C. Discipline both nurses for unprofessional behavior
D. Ignore the conflict and allow it to resolve naturally
Correct Answer: B
Rationale: The best approach to conflict resolution begins with facilitating open
communication between the involved parties in a private setting. This promotes collaboration
and allows each nurse to express concerns. Reassignment, discipline, and ignoring the conflict
do not address the underlying issue.
4. A nurse is caring for a client who speaks a language different from the nurse's. Which of the
following actions should the nurse take?
A. Ask the client's family member to interpret
B. Request an interpreter of the same sex as the client when possible
C. Speak slowly and loudly while using gestures
D. Provide written instructions in English
Correct Answer: B
Rationale: When caring for a client with limited English proficiency, the nurse should use a
professional medical interpreter, preferably one of the same sex if the client prefers. Family
members should not be used as interpreters due to potential for errors and confidentiality
concerns. Speaking loudly does not improve comprehension.
5. A nurse is reviewing advance directives with a middle adult client. Which of the following
statements by the client indicates understanding?
A. "I can designate my partner as my health care surrogate."
B. "My family can override my living will if they disagree."
C. "Advance directives only apply when I am terminally ill."
D. "I need a lawyer to create a living will."
Correct Answer: A
Rationale: Designating a health care surrogate is a component of advance directives. The
client can appoint someone to make healthcare decisions if they become unable to do so.
Advance directives apply in various situations beyond terminal illness, and a lawyer is not
required.
6. A nurse is preparing to transfer a client from the ICU to the medical floor. Which of the
following information should the nurse include in the change-of-shift report?
,A. The client's admission date and medical record number
B. The time of the client's last dose of pain medication
C. The client's preferred television channel
D. The names of all family members who have visited
Correct Answer: B
Rationale: An effective handoff report includes recent changes and priority situations
affecting the client's condition. The time of the last pain medication dose is essential for the
receiving nurse to anticipate the next dose. Administrative details and preferences are less
critical.
7. A nurse is reviewing a newly licensed nurse's documentation. Which of the following
notations indicates correct documentation?
A. "OOB with assistance for breakfast"
B. "Given 2 mg MSO4 IM for report of pain"
C. "Dressing changed qd"
D. "Administered 8 u regular insulin sq."
Correct Answer: A
Rationale: "OOB with assistance for breakfast" uses approved abbreviations and clearly
describes the activity. "MSO4" can be confused with magnesium sulfate, "qd" is on the Do Not
Use list (use "daily"), and "u" should be written as "units."
8. A nurse is planning care for a client who has a new prescription for a low-sodium diet.
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh apples
B. Canned soup
C. Grilled chicken breast
D. Steamed broccoli
Correct Answer: B
Rationale: Canned soups are high in sodium due to added salt as a preservative. Fresh
fruits, unprocessed meats, and fresh vegetables are naturally low in sodium.
9. A nurse is assessing a client's ability to sign informed consent. Which of the following
findings indicates the client is capable of providing consent?
A. The client is able to accurately describe the upcoming procedure.
B. The client asks the nurse what procedure is scheduled.
, C. The client's family member is present and agrees with the procedure.
D. The client has a temperature of 38.2°C (100.8°F).
Correct Answer: A
Rationale: For informed consent to be valid, the client must understand the procedure, its
risks, and benefits. The ability to accurately describe the procedure indicates comprehension.
Family presence, fever, or lack of knowledge do not indicate capacity.
10. A nurse manager is planning to use a democratic leadership style. Which of the following
actions demonstrates this style?
A. Making decisions independently and informing staff afterward
B. Seeking input from staff nurses before making decisions
C. Allowing staff to set their own schedules without guidelines
D. Delegating all management tasks to the charge nurse
Correct Answer: B
Rationale: Democratic leadership involves including team members in decision-making and
encouraging staff participation. This differs from autocratic (independent decisions) or laissez-
faire (no guidance) styles.
11. A nurse is caring for a client who has a history of falls. Which of the following
interventions should the nurse include in the plan of care?
A. Apply a yellow wristband to identify fall risk.
B. Keep the bed in the highest position.
C. Use a chair alarm only for confused clients.
D. Restrict all client activity to prevent falls.
Correct Answer: A
Rationale: Yellow wristbands are standard for identifying fall risk clients. The bed should be
kept in the lowest position, alarms should be used for at-risk clients regardless of confusion, and
activity should not be restricted as this leads to deconditioning.
12. A nurse is preparing to administer a blood transfusion. Which of the following actions
should the nurse take first?
A. Verify the client's identity with a second nurse.
B. Obtain the client's vital signs.
C. Explain the procedure to the client.
D. Prime the IV tubing with 0.9% sodium chloride.
