RN ATI capstone proctored comprehensive assessment 2019 B
Management of Care
1. A nurse is delegating tasks to an LPN and a UAP. Which task is
most appropriate to delegate to the UAP?
A. Administering oral metformin
B. Reinforcing teaching about a low-sodium diet
C. Obtaining a blood pressure on a stable client
D. Inserting a urinary catheter
Correct Answer: C
Explanation / Rationale: Obtaining vital signs on a stable client is within
UAP scope of practice. Medication administration and invasive procedures
require an LPN or RN; teaching is an RN responsibility.
2. A client states, "I don't want that student nurse caring for me."
What is the nurse's best response?
A. "The student is fully supervised, so it's fine."
B. "I'll respect your wishes and assign a different nurse."
C. "You don't have a choice about who provides your care."
D. "Let me explain why students need practice."
Correct Answer: B
Explanation / Rationale: Clients have the right to refuse care from specific
providers. Advocacy means honoring the request without coercion.
3. A nurse is prioritizing care for four clients. Which client should be
assessed first?
A. Client requesting pain medication for a headache
B. Client with new-onset shortness of breath and crackles
C. Client awaiting discharge teaching
D. Client with a blood glucose of 150 mg/dL
,Correct Answer: B
Explanation / Rationale: Airway/breathing takes priority (ABCs). New
dyspnea with crackles suggests fluid overload or pulmonary edema.
4. Which action best demonstrates the nurse acting as a client
advocate?
A. Documenting vital signs accurately
B. Reporting a suspected medication error to the provider
C. Completing an incident report
D. Verifying informed consent was obtained appropriately
Correct Answer: D
Explanation / Rationale: Ensuring informed consent was obtained
appropriately protects the client's right to autonomy and self-determination,
which is the essence of advocacy.
5. A nurse manager is planning to make changes to the current
scheduling system. To facilitate staff acceptance, which action should
the nurse manager take first?
A. Provide information about scheduling issues to the staff
B. Implement the change immediately
C. Ask for feedback after the change is implemented
D. Send an email outlining the new schedule
Correct Answer: A
Explanation / Rationale: The unfreezing stage of change requires
increasing understanding of why change is needed. Providing information
about scheduling issues first facilitates acceptance.
6. A nurse is teaching about safe handling of formula to a client who
is postpartum and bottle-feeding. Which statement indicates an
understanding?
A. "I should use sterile water when I mix it with powdered formula."
B. "I should boil tap water for 2 minutes before I mix it with powdered
formula."
C. "I should mix the formula with cold water."
D. "I should prepare a week's worth of formula at a time."
,Correct Answer: B
Explanation / Rationale: Boiling tap water for 2 minutes before mixing with
powdered formula kills bacteria and ensures safety. Sterile water is not
required for routine formula preparation.
7. A nurse is preparing to leave the room of a client who is on
isolation precautions. Which action should the nurse take when
removing a tight 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. Leave the mask on until outside the room
D. Remove the mask by pulling it down to the neck
Correct Answer: A
Explanation / Rationale: The mask should be removed by holding the ties
and moving it away from the face to prevent contamination. Touching the
front of the mask contaminates the hands.
8. A nurse is documenting an assessment in a client's electronic
health record when an assistive personnel asks to enter the morning
blood glucose. Which action should the nurse take?
A. Allow the UAP to enter the data
B. Enter the data personally
C. Ask the UAP to report the value verbally
D. Document the value under the UAP's name
Correct Answer: B
Explanation / Rationale: The nurse is responsible for documenting
assessment data. UAPs should report findings to the nurse, who then
documents them.
9. A nurse is working in an emergency department triaging four
clients. Which client should the nurse recommend for treatment first?
A. A middle adult client who has unstable vital signs
B. A client with a minor laceration
, C. A client requesting a work note
D. A client with a sprained ankle
Correct Answer: A
Explanation / Rationale: Unstable vital signs indicate a life-threatening
condition requiring immediate treatment. The other clients have non-urgent
complaints.
10. A nurse is caring for a client who has active tuberculosis. Which
action should the nurse take?
A. Assign the client to a private room with negative air pressure
B. Place the client in a room with another TB client
C. Wear a surgical mask when entering the room
D. Keep the door open for air circulation
Correct Answer: A
Explanation / Rationale: TB requires airborne precautions, including a
private room with negative air pressure and a fitted N95 respirator. A
surgical mask is insufficient.
11. A nurse is admitting a client who has pulmonary tuberculosis.
Which transmission-based precautions should the nurse initiate?
A. Airborne
B. Contact
C. Droplet
D. Standard
Correct Answer: A
Explanation / Rationale: Pulmonary TB is transmitted via airborne
droplets and requires airborne precautions, including a negative pressure
room and N95 respirator.
12. A nurse is reviewing a client's new prescriptions. Which
abbreviation should the nurse clarify with the provider?
A. Enoxaparin 40 mg SQ QD
B. Lisinopril 10 mg PO daily
C. Metformin 500 mg PO BID
D. Acetaminophen 650 mg PO Q6H PRN
Management of Care
1. A nurse is delegating tasks to an LPN and a UAP. Which task is
most appropriate to delegate to the UAP?
A. Administering oral metformin
B. Reinforcing teaching about a low-sodium diet
C. Obtaining a blood pressure on a stable client
D. Inserting a urinary catheter
Correct Answer: C
Explanation / Rationale: Obtaining vital signs on a stable client is within
UAP scope of practice. Medication administration and invasive procedures
require an LPN or RN; teaching is an RN responsibility.
2. A client states, "I don't want that student nurse caring for me."
What is the nurse's best response?
A. "The student is fully supervised, so it's fine."
B. "I'll respect your wishes and assign a different nurse."
C. "You don't have a choice about who provides your care."
D. "Let me explain why students need practice."
Correct Answer: B
Explanation / Rationale: Clients have the right to refuse care from specific
providers. Advocacy means honoring the request without coercion.
3. A nurse is prioritizing care for four clients. Which client should be
assessed first?
A. Client requesting pain medication for a headache
B. Client with new-onset shortness of breath and crackles
C. Client awaiting discharge teaching
D. Client with a blood glucose of 150 mg/dL
,Correct Answer: B
Explanation / Rationale: Airway/breathing takes priority (ABCs). New
dyspnea with crackles suggests fluid overload or pulmonary edema.
4. Which action best demonstrates the nurse acting as a client
advocate?
A. Documenting vital signs accurately
B. Reporting a suspected medication error to the provider
C. Completing an incident report
D. Verifying informed consent was obtained appropriately
Correct Answer: D
Explanation / Rationale: Ensuring informed consent was obtained
appropriately protects the client's right to autonomy and self-determination,
which is the essence of advocacy.
5. A nurse manager is planning to make changes to the current
scheduling system. To facilitate staff acceptance, which action should
the nurse manager take first?
A. Provide information about scheduling issues to the staff
B. Implement the change immediately
C. Ask for feedback after the change is implemented
D. Send an email outlining the new schedule
Correct Answer: A
Explanation / Rationale: The unfreezing stage of change requires
increasing understanding of why change is needed. Providing information
about scheduling issues first facilitates acceptance.
6. A nurse is teaching about safe handling of formula to a client who
is postpartum and bottle-feeding. Which statement indicates an
understanding?
A. "I should use sterile water when I mix it with powdered formula."
B. "I should boil tap water for 2 minutes before I mix it with powdered
formula."
C. "I should mix the formula with cold water."
D. "I should prepare a week's worth of formula at a time."
,Correct Answer: B
Explanation / Rationale: Boiling tap water for 2 minutes before mixing with
powdered formula kills bacteria and ensures safety. Sterile water is not
required for routine formula preparation.
7. A nurse is preparing to leave the room of a client who is on
isolation precautions. Which action should the nurse take when
removing a tight 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. Leave the mask on until outside the room
D. Remove the mask by pulling it down to the neck
Correct Answer: A
Explanation / Rationale: The mask should be removed by holding the ties
and moving it away from the face to prevent contamination. Touching the
front of the mask contaminates the hands.
8. A nurse is documenting an assessment in a client's electronic
health record when an assistive personnel asks to enter the morning
blood glucose. Which action should the nurse take?
A. Allow the UAP to enter the data
B. Enter the data personally
C. Ask the UAP to report the value verbally
D. Document the value under the UAP's name
Correct Answer: B
Explanation / Rationale: The nurse is responsible for documenting
assessment data. UAPs should report findings to the nurse, who then
documents them.
9. A nurse is working in an emergency department triaging four
clients. Which client should the nurse recommend for treatment first?
A. A middle adult client who has unstable vital signs
B. A client with a minor laceration
, C. A client requesting a work note
D. A client with a sprained ankle
Correct Answer: A
Explanation / Rationale: Unstable vital signs indicate a life-threatening
condition requiring immediate treatment. The other clients have non-urgent
complaints.
10. A nurse is caring for a client who has active tuberculosis. Which
action should the nurse take?
A. Assign the client to a private room with negative air pressure
B. Place the client in a room with another TB client
C. Wear a surgical mask when entering the room
D. Keep the door open for air circulation
Correct Answer: A
Explanation / Rationale: TB requires airborne precautions, including a
private room with negative air pressure and a fitted N95 respirator. A
surgical mask is insufficient.
11. A nurse is admitting a client who has pulmonary tuberculosis.
Which transmission-based precautions should the nurse initiate?
A. Airborne
B. Contact
C. Droplet
D. Standard
Correct Answer: A
Explanation / Rationale: Pulmonary TB is transmitted via airborne
droplets and requires airborne precautions, including a negative pressure
room and N95 respirator.
12. A nurse is reviewing a client's new prescriptions. Which
abbreviation should the nurse clarify with the provider?
A. Enoxaparin 40 mg SQ QD
B. Lisinopril 10 mg PO daily
C. Metformin 500 mg PO BID
D. Acetaminophen 650 mg PO Q6H PRN
