ATI CAPSTONE COMPREHENSIVE
NURSING REVIEW QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is caring for a client who is 24 hours postoperative following an abdominal surgery.
The client suddenly reports feeling a ‘pop’ and the nurse notes viscera protruding through the
incision. Which of the following actions should the nurse take first?
A. Cover the wound with a sterile dressing moistened with normal saline.
B. Place the client in a high-Fowler’s position.
C. Notify the surgeon immediately.
D. Apply a tight abdominal binder to the site.
Answer: A
Conceptual Explanation: The first priority for wound evisceration is to protect the
internal organs by covering them with a sterile, saline-moistened dressing to prevent
drying and infection, followed by notifying the provider.
2. A nurse is caring for a client who has a prescription for a magnesium sulfate infusion for
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Tachycardia
,B. Respiratory rate of 10/min
C. Hyperreflexia
D. Increased urinary output
Answer: B
Conceptual Explanation: Signs of magnesium toxicity include bradypnea (respiratory rate
< 12/min), absent deep tendon reflexes, and decreased urinary output. Tachycardia and
hyperreflexia are not associated with toxicity; in fact, hyporeflexia occurs.
3. A nurse in the emergency department is triaging four clients. Which of the following clients
should the nurse prioritize for treatment?
A. A client who has a broken wrist and reports a pain level of 8/10.
B. A client who is reporting chest pressure and diaphoresis.
C. A client who has a 2-cm laceration on the forehead.
D. A client who has a fever of 38.9 C (102 F) and a cough.
Answer: B
Conceptual Explanation: Chest pressure and diaphoresis are indicative of a potential
myocardial infarction, making this client the highest priority for immediate assessment and
intervention according to the ABC (Airway, Breathing, Circulation) framework.
, 4. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the
following findings should the nurse report to the provider before administering the
medication?
A. Potassium level of 3.2 mEq/L
B. Apical pulse of 68/min
C. Digoxin level of 1.2 ng/mL
D. Weight gain of 1 lb in 24 hours
Answer: A
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) increases the risk of
digoxin toxicity. The pulse of 68/min is within normal limits, and the digoxin level is within
the therapeutic range (0.8 to 2.0 ng/mL).
5. A nurse is caring for a client who has a new diagnosis of Type 1 Diabetes Mellitus. The
nurse should identify that which of the following is a classic clinical manifestation of diabetic
ketoacidosis (DKA)?
A. Bradypnea
B. Peripheral edema
C. Hypertension
D. Kussmaul respirations
Answer: D
NURSING REVIEW QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is caring for a client who is 24 hours postoperative following an abdominal surgery.
The client suddenly reports feeling a ‘pop’ and the nurse notes viscera protruding through the
incision. Which of the following actions should the nurse take first?
A. Cover the wound with a sterile dressing moistened with normal saline.
B. Place the client in a high-Fowler’s position.
C. Notify the surgeon immediately.
D. Apply a tight abdominal binder to the site.
Answer: A
Conceptual Explanation: The first priority for wound evisceration is to protect the
internal organs by covering them with a sterile, saline-moistened dressing to prevent
drying and infection, followed by notifying the provider.
2. A nurse is caring for a client who has a prescription for a magnesium sulfate infusion for
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Tachycardia
,B. Respiratory rate of 10/min
C. Hyperreflexia
D. Increased urinary output
Answer: B
Conceptual Explanation: Signs of magnesium toxicity include bradypnea (respiratory rate
< 12/min), absent deep tendon reflexes, and decreased urinary output. Tachycardia and
hyperreflexia are not associated with toxicity; in fact, hyporeflexia occurs.
3. A nurse in the emergency department is triaging four clients. Which of the following clients
should the nurse prioritize for treatment?
A. A client who has a broken wrist and reports a pain level of 8/10.
B. A client who is reporting chest pressure and diaphoresis.
C. A client who has a 2-cm laceration on the forehead.
D. A client who has a fever of 38.9 C (102 F) and a cough.
Answer: B
Conceptual Explanation: Chest pressure and diaphoresis are indicative of a potential
myocardial infarction, making this client the highest priority for immediate assessment and
intervention according to the ABC (Airway, Breathing, Circulation) framework.
, 4. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the
following findings should the nurse report to the provider before administering the
medication?
A. Potassium level of 3.2 mEq/L
B. Apical pulse of 68/min
C. Digoxin level of 1.2 ng/mL
D. Weight gain of 1 lb in 24 hours
Answer: A
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) increases the risk of
digoxin toxicity. The pulse of 68/min is within normal limits, and the digoxin level is within
the therapeutic range (0.8 to 2.0 ng/mL).
5. A nurse is caring for a client who has a new diagnosis of Type 1 Diabetes Mellitus. The
nurse should identify that which of the following is a classic clinical manifestation of diabetic
ketoacidosis (DKA)?
A. Bradypnea
B. Peripheral edema
C. Hypertension
D. Kussmaul respirations
Answer: D
