RN ATI capstone proctored comprehensive
assessment 2019 A
1. A nurse is prioritizing care for four clients. Which client should the nurse assess first?
A. A client 2 days postoperative reporting incisional pain rated 5/10
B. A client with COPD reporting increased shortness of breath and anxiety
C. A client requesting assistance to ambulate for the first time
D. A client with a urinary tract infection requesting cranberry juice
Correct Answer: B
Rationale: Increased shortness of breath with anxiety suggests possible respiratory
distress/hypoxemia, an immediate threat to airway and breathing (ABC priority). Pain rated
5/10, first-time ambulation, and a UTI request are important but not immediately life-
threatening.
2. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Administering a scheduled oral medication
B. Teaching a client how to use an incentive spirometer
C. Measuring and recording a client's intake and output
D. Assessing a client's postoperative wound for signs of infection
Correct Answer: C
Rationale: Measuring/recording I&O is a routine, non-invasive task within AP scope.
Medication administration, client teaching, and assessment require the nurse's clinical
judgment and licensure.
3. A nurse is using the SBAR communication tool. Which information belongs in the "R"
component?
A. "The client's heart rate is 118 and blood pressure is 88/54."
B. "I think the client may be developing sepsis and needs immediate evaluation."
C. "The client is a 68-year-old admitted for pneumonia."
D. "I am calling because the client's condition has changed."
Correct Answer: B
Rationale: "R" = Recommendation. The nurse states what she thinks is happening and what
,is needed. Vital signs are assessment (A), demographics are situation/background, and the
reason for calling is the situation.
4. A nurse witnesses a coworker diverting controlled substances. Which action should the
nurse take first?
A. Confront the coworker directly
B. Report the observation to the nurse manager or appropriate authority
C. Document the observation in the client's chart
D. Ignore the behavior to avoid conflict
Correct Answer: B
Rationale: Diversion is a serious safety and legal issue; the nurse must report through the
chain of command/appropriate authority. Confrontation may escalate risk, and client charts are
not the place for employee-related documentation.
5. A nurse is preparing to discharge a client who speaks limited English. Which action best
ensures informed consent and understanding?
A. Ask a family member to interpret
B. Use a certified medical interpreter
C. Provide written instructions in English only
D. Speak loudly and slowly in English
Correct Answer: B
Rationale: A certified medical interpreter ensures accurate communication and meets
legal/ethical standards. Family members may misinterpret or filter information; written English-
only materials and loud speech do not address language barriers.
6. A nurse is reviewing an informed consent form signed by a client prior to surgery. The client
states, "I don't remember what the doctor said." Which action should the nurse take?
A. Witness the consent anyway since it is signed
B. Notify the provider so the consent process can be repeated
C. Explain the procedure to the client and have her re-sign
D. Tell the client the surgeon will answer questions after surgery
Correct Answer: B
Rationale: Informed consent requires the client understand the procedure; the provider
,obtains consent. If the client doesn't remember, the nurse notifies the provider to re-explain.
Nurses witness consent but do not obtain it or provide the initial explanation.
7. Which client assignment is most appropriate for a newly licensed nurse?
A. A client receiving chemotherapy with a new central line
B. A stable client 1 day postoperative following an appendectomy
C. A client in acute respiratory failure requiring frequent suctioning
D. A client with a new tracheostomy requiring frequent dressing changes
Correct Answer: B
Rationale: A stable postoperative client has predictable needs appropriate for a new nurse.
Chemotherapy with a new central line, acute respiratory failure, and a new tracheostomy
require advanced assessment and skill.
8. A nurse is caring for a client who is Jehovah's Witness and refuses a blood transfusion.
Which action should the nurse take?
A. Administer the transfusion anyway to save the client's life
B. Respect the client's right to refuse and document the refusal
C. Ask the family to convince the client
D. Transfer the client to another facility
Correct Answer: B
Rationale: Competent adults have the right to refuse treatment based on religious beliefs.
The nurse documents the refusal and ensures the provider is notified; the nurse cannot override
autonomy.
9. A nurse is acting as an advocate for a client. Which action best demonstrates advocacy?
A. Making decisions for the client
B. Ensuring the client's wishes and rights are respected
C. Avoiding involvement in ethical dilemmas
D. Following provider orders without question
Correct Answer: B
Rationale: Advocacy means supporting and protecting the client's rights, wishes, and
autonomy, not making decisions for them or blindly following orders.
, 10. A nurse is reviewing advance directives with a client. Which statement by the nurse is
correct?
A. "A living will can only be completed by a client who is terminally ill."
B. "A durable power of attorney for health care designates someone to make decisions if you
become unable."
C. "Advance directives must be notarized to be valid in all states."
D. "You cannot change your advance directive once it is signed."
Correct Answer: B
Rationale: A durable power of attorney for health care (health care proxy) names a
surrogate decision-maker. Living wills can be completed by any competent adult, requirements
vary by state, and directives can be revised.
11. A nurse is preparing to administer a unit of packed RBCs. Which action is a priority?
A. Verify the blood type with one nurse
B. Begin the transfusion within 30 minutes of obtaining the unit
C. Use a 20-gauge or larger IV catheter
D. Premedicate with acetaminophen routinely
Correct Answer: B
Rationale: Blood must be started within 30 minutes of receipt and infused within 4 hours.
Two nurses verify blood type. A 20-gauge or larger is preferred but not the priority over timely
initiation; routine premedication is not standard.
12. A nurse is completing an incident report after a client fall. Which statement is correct?
A. Document the incident report in the client's medical record
B. Include the incident report in the client's chart as a progress note
C. Do not document the incident report in the client's record; document the fall in the nurses'
notes
D. Ask the client to sign the incident report
Correct Answer: C
Rationale: Incident reports are internal quality documents and are not placed in the client's
chart. The fall and assessment findings are documented objectively in the medical record.
assessment 2019 A
1. A nurse is prioritizing care for four clients. Which client should the nurse assess first?
A. A client 2 days postoperative reporting incisional pain rated 5/10
B. A client with COPD reporting increased shortness of breath and anxiety
C. A client requesting assistance to ambulate for the first time
D. A client with a urinary tract infection requesting cranberry juice
Correct Answer: B
Rationale: Increased shortness of breath with anxiety suggests possible respiratory
distress/hypoxemia, an immediate threat to airway and breathing (ABC priority). Pain rated
5/10, first-time ambulation, and a UTI request are important but not immediately life-
threatening.
2. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Administering a scheduled oral medication
B. Teaching a client how to use an incentive spirometer
C. Measuring and recording a client's intake and output
D. Assessing a client's postoperative wound for signs of infection
Correct Answer: C
Rationale: Measuring/recording I&O is a routine, non-invasive task within AP scope.
Medication administration, client teaching, and assessment require the nurse's clinical
judgment and licensure.
3. A nurse is using the SBAR communication tool. Which information belongs in the "R"
component?
A. "The client's heart rate is 118 and blood pressure is 88/54."
B. "I think the client may be developing sepsis and needs immediate evaluation."
C. "The client is a 68-year-old admitted for pneumonia."
D. "I am calling because the client's condition has changed."
Correct Answer: B
Rationale: "R" = Recommendation. The nurse states what she thinks is happening and what
,is needed. Vital signs are assessment (A), demographics are situation/background, and the
reason for calling is the situation.
4. A nurse witnesses a coworker diverting controlled substances. Which action should the
nurse take first?
A. Confront the coworker directly
B. Report the observation to the nurse manager or appropriate authority
C. Document the observation in the client's chart
D. Ignore the behavior to avoid conflict
Correct Answer: B
Rationale: Diversion is a serious safety and legal issue; the nurse must report through the
chain of command/appropriate authority. Confrontation may escalate risk, and client charts are
not the place for employee-related documentation.
5. A nurse is preparing to discharge a client who speaks limited English. Which action best
ensures informed consent and understanding?
A. Ask a family member to interpret
B. Use a certified medical interpreter
C. Provide written instructions in English only
D. Speak loudly and slowly in English
Correct Answer: B
Rationale: A certified medical interpreter ensures accurate communication and meets
legal/ethical standards. Family members may misinterpret or filter information; written English-
only materials and loud speech do not address language barriers.
6. A nurse is reviewing an informed consent form signed by a client prior to surgery. The client
states, "I don't remember what the doctor said." Which action should the nurse take?
A. Witness the consent anyway since it is signed
B. Notify the provider so the consent process can be repeated
C. Explain the procedure to the client and have her re-sign
D. Tell the client the surgeon will answer questions after surgery
Correct Answer: B
Rationale: Informed consent requires the client understand the procedure; the provider
,obtains consent. If the client doesn't remember, the nurse notifies the provider to re-explain.
Nurses witness consent but do not obtain it or provide the initial explanation.
7. Which client assignment is most appropriate for a newly licensed nurse?
A. A client receiving chemotherapy with a new central line
B. A stable client 1 day postoperative following an appendectomy
C. A client in acute respiratory failure requiring frequent suctioning
D. A client with a new tracheostomy requiring frequent dressing changes
Correct Answer: B
Rationale: A stable postoperative client has predictable needs appropriate for a new nurse.
Chemotherapy with a new central line, acute respiratory failure, and a new tracheostomy
require advanced assessment and skill.
8. A nurse is caring for a client who is Jehovah's Witness and refuses a blood transfusion.
Which action should the nurse take?
A. Administer the transfusion anyway to save the client's life
B. Respect the client's right to refuse and document the refusal
C. Ask the family to convince the client
D. Transfer the client to another facility
Correct Answer: B
Rationale: Competent adults have the right to refuse treatment based on religious beliefs.
The nurse documents the refusal and ensures the provider is notified; the nurse cannot override
autonomy.
9. A nurse is acting as an advocate for a client. Which action best demonstrates advocacy?
A. Making decisions for the client
B. Ensuring the client's wishes and rights are respected
C. Avoiding involvement in ethical dilemmas
D. Following provider orders without question
Correct Answer: B
Rationale: Advocacy means supporting and protecting the client's rights, wishes, and
autonomy, not making decisions for them or blindly following orders.
, 10. A nurse is reviewing advance directives with a client. Which statement by the nurse is
correct?
A. "A living will can only be completed by a client who is terminally ill."
B. "A durable power of attorney for health care designates someone to make decisions if you
become unable."
C. "Advance directives must be notarized to be valid in all states."
D. "You cannot change your advance directive once it is signed."
Correct Answer: B
Rationale: A durable power of attorney for health care (health care proxy) names a
surrogate decision-maker. Living wills can be completed by any competent adult, requirements
vary by state, and directives can be revised.
11. A nurse is preparing to administer a unit of packed RBCs. Which action is a priority?
A. Verify the blood type with one nurse
B. Begin the transfusion within 30 minutes of obtaining the unit
C. Use a 20-gauge or larger IV catheter
D. Premedicate with acetaminophen routinely
Correct Answer: B
Rationale: Blood must be started within 30 minutes of receipt and infused within 4 hours.
Two nurses verify blood type. A 20-gauge or larger is preferred but not the priority over timely
initiation; routine premedication is not standard.
12. A nurse is completing an incident report after a client fall. Which statement is correct?
A. Document the incident report in the client's medical record
B. Include the incident report in the client's chart as a progress note
C. Do not document the incident report in the client's record; document the fall in the nurses'
notes
D. Ask the client to sign the incident report
Correct Answer: C
Rationale: Incident reports are internal quality documents and are not placed in the client's
chart. The fall and assessment findings are documented objectively in the medical record.
