ATI CAPSTONE EXAM 1/ 300 ACTUAL
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
Section 1: Fundamentals and Safety (Questions 1–40)
1. A nurse is caring for a client who reports shortness of breath. Which action
should the nurse take first?
A. Obtain the client's oxygen saturation
B. Administer prescribed oxygen
C. Ask the client when the dyspnea began
D. Notify the provider
Correct Answer: A
Rationale: The nurse should first assess the client's respiratory status, including
oxygen saturation, to determine severity and guide interventions. Assessment
precedes treatment unless the client has an immediately obvious life-threatening
emergency.
2. Which finding requires the nurse to intervene immediately?
A. Blood pressure 128/76 mm Hg
B. Respiratory rate 8/min
C. Temperature 37.1°C (98.8°F)
D. Pulse 82/min
Correct Answer: B
Rationale: A respiratory rate of 8/min indicates bradypnea and possible respiratory
depression. Airway and breathing take priority.
3. Which action demonstrates the evaluation phase of the nursing process?
A. Identifying a client's risk for falls
B. Developing a fall-prevention plan
C. Implementing a bed alarm
D. Determining whether the client remained free from falls
,Correct Answer: D
Rationale: Evaluation determines whether nursing interventions achieved the
desired outcomes.
4. A nurse identifies that a client is at risk for impaired skin integrity. Which
intervention is appropriate?
A. Massage reddened areas
B. Reposition the client regularly
C. Keep the client's skin continuously moist
D. Place a donut-shaped cushion beneath the sacrum
Correct Answer: B
Rationale: Regular repositioning reduces prolonged pressure and helps prevent
pressure injuries. Massaging reddened areas and donut cushions can damage tissue.
5. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting pain of 6/10 after surgery
C. Client with new confusion and oxygen saturation of 86%
D. Client requesting discharge instructions
Correct Answer: C
Rationale: New confusion with significant hypoxemia indicates an immediate
physiologic problem. Airway and breathing take priority.
6. Which statement by a nurse reflects appropriate use of evidence-based practice?
A. "I always use the same intervention because it worked once."
B. "I use current evidence along with clinical expertise and client preferences."
C. "Research findings are more important than client preferences."
D. "Provider preference determines the best nursing intervention."
Correct Answer: B
Rationale: Evidence-based practice integrates current research evidence, clinical
expertise, and patient preferences/values.
7. Which nursing action is an example of primary prevention?
A. Screening for hypertension
B. Administering a childhood vaccine
C. Providing rehabilitation after a stroke
,D. Monitoring a client with established diabetes
Correct Answer: B
Rationale: Primary prevention prevents disease before it occurs. Immunization is a
classic example.
8. A client refuses a prescribed treatment. Which action should the nurse take?
A. Administer the treatment because it was prescribed
B. Ask the client why they are refusing
C. Tell the client refusal will delay discharge
D. Ask a family member to convince the client
Correct Answer: B
Rationale: A competent adult has the right to refuse treatment. The nurse should
explore the client's concerns, provide information, and respect autonomy.
9. Which outcome is written correctly?
A. Client will feel better.
B. Nurse will monitor blood pressure.
C. Client will maintain oxygen saturation above 94% during ambulation.
D. Nurse will encourage fluids.
Correct Answer: C
Rationale: An appropriate outcome is client-centered, measurable, specific, and
time/action oriented.
10. A nurse enters a client's room and finds the client lying on the floor in a puddle
of water. Which statement should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Correct Answer: D
Rationale: Incident reports should document only objective, factual observations
without assigning blame or including unverified statements.
11. A nurse is preparing to administer a medication through a nasogastric tube.
Which action should the nurse take first?
, A. Flush the tube with water
B. Verify tube placement
C. Crush the medication
D. Position the client supine
Correct Answer: B
Rationale: Verifying tube placement is essential before administering any
medication through a nasogastric tube to prevent aspiration.
12. A nurse is caring for a client who has a new prescription for a clear liquid diet.
Which of the following items should the nurse offer the client?
A. Vanilla ice cream
B. Orange gelatin
C. Cream of tomato soup
D. Hot chocolate
Correct Answer: B
Rationale: Orange gelatin is a clear liquid. The other options are full liquids or
contain dairy, which are not allowed on a clear liquid diet.
13. Which action should the nurse take to prevent a fall in an older adult client?
A. Keep the bed in the highest position
B. Ensure the call light is within reach
C. Apply bilateral wrist restraints
D. Keep the side rails down
Correct Answer: B
Rationale: Ensuring the call light is within reach promotes safety and allows the
client to request assistance. Restraints require a provider order and are a last resort.
14. A nurse is performing a sterile dressing change. Which action demonstrates
proper sterile technique?
A. Turning away from the sterile field to sneeze
B. Placing sterile supplies on the bedside table
C. Reaching over the sterile field to obtain supplies
D. Keeping the sterile field below waist level
Correct Answer: A
Rationale: The nurse should turn away from the sterile field to sneeze or cough to
prevent contamination.
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
Section 1: Fundamentals and Safety (Questions 1–40)
1. A nurse is caring for a client who reports shortness of breath. Which action
should the nurse take first?
A. Obtain the client's oxygen saturation
B. Administer prescribed oxygen
C. Ask the client when the dyspnea began
D. Notify the provider
Correct Answer: A
Rationale: The nurse should first assess the client's respiratory status, including
oxygen saturation, to determine severity and guide interventions. Assessment
precedes treatment unless the client has an immediately obvious life-threatening
emergency.
2. Which finding requires the nurse to intervene immediately?
A. Blood pressure 128/76 mm Hg
B. Respiratory rate 8/min
C. Temperature 37.1°C (98.8°F)
D. Pulse 82/min
Correct Answer: B
Rationale: A respiratory rate of 8/min indicates bradypnea and possible respiratory
depression. Airway and breathing take priority.
3. Which action demonstrates the evaluation phase of the nursing process?
A. Identifying a client's risk for falls
B. Developing a fall-prevention plan
C. Implementing a bed alarm
D. Determining whether the client remained free from falls
,Correct Answer: D
Rationale: Evaluation determines whether nursing interventions achieved the
desired outcomes.
4. A nurse identifies that a client is at risk for impaired skin integrity. Which
intervention is appropriate?
A. Massage reddened areas
B. Reposition the client regularly
C. Keep the client's skin continuously moist
D. Place a donut-shaped cushion beneath the sacrum
Correct Answer: B
Rationale: Regular repositioning reduces prolonged pressure and helps prevent
pressure injuries. Massaging reddened areas and donut cushions can damage tissue.
5. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting pain of 6/10 after surgery
C. Client with new confusion and oxygen saturation of 86%
D. Client requesting discharge instructions
Correct Answer: C
Rationale: New confusion with significant hypoxemia indicates an immediate
physiologic problem. Airway and breathing take priority.
6. Which statement by a nurse reflects appropriate use of evidence-based practice?
A. "I always use the same intervention because it worked once."
B. "I use current evidence along with clinical expertise and client preferences."
C. "Research findings are more important than client preferences."
D. "Provider preference determines the best nursing intervention."
Correct Answer: B
Rationale: Evidence-based practice integrates current research evidence, clinical
expertise, and patient preferences/values.
7. Which nursing action is an example of primary prevention?
A. Screening for hypertension
B. Administering a childhood vaccine
C. Providing rehabilitation after a stroke
,D. Monitoring a client with established diabetes
Correct Answer: B
Rationale: Primary prevention prevents disease before it occurs. Immunization is a
classic example.
8. A client refuses a prescribed treatment. Which action should the nurse take?
A. Administer the treatment because it was prescribed
B. Ask the client why they are refusing
C. Tell the client refusal will delay discharge
D. Ask a family member to convince the client
Correct Answer: B
Rationale: A competent adult has the right to refuse treatment. The nurse should
explore the client's concerns, provide information, and respect autonomy.
9. Which outcome is written correctly?
A. Client will feel better.
B. Nurse will monitor blood pressure.
C. Client will maintain oxygen saturation above 94% during ambulation.
D. Nurse will encourage fluids.
Correct Answer: C
Rationale: An appropriate outcome is client-centered, measurable, specific, and
time/action oriented.
10. A nurse enters a client's room and finds the client lying on the floor in a puddle
of water. Which statement should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed
down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Correct Answer: D
Rationale: Incident reports should document only objective, factual observations
without assigning blame or including unverified statements.
11. A nurse is preparing to administer a medication through a nasogastric tube.
Which action should the nurse take first?
, A. Flush the tube with water
B. Verify tube placement
C. Crush the medication
D. Position the client supine
Correct Answer: B
Rationale: Verifying tube placement is essential before administering any
medication through a nasogastric tube to prevent aspiration.
12. A nurse is caring for a client who has a new prescription for a clear liquid diet.
Which of the following items should the nurse offer the client?
A. Vanilla ice cream
B. Orange gelatin
C. Cream of tomato soup
D. Hot chocolate
Correct Answer: B
Rationale: Orange gelatin is a clear liquid. The other options are full liquids or
contain dairy, which are not allowed on a clear liquid diet.
13. Which action should the nurse take to prevent a fall in an older adult client?
A. Keep the bed in the highest position
B. Ensure the call light is within reach
C. Apply bilateral wrist restraints
D. Keep the side rails down
Correct Answer: B
Rationale: Ensuring the call light is within reach promotes safety and allows the
client to request assistance. Restraints require a provider order and are a last resort.
14. A nurse is performing a sterile dressing change. Which action demonstrates
proper sterile technique?
A. Turning away from the sterile field to sneeze
B. Placing sterile supplies on the bedside table
C. Reaching over the sterile field to obtain supplies
D. Keeping the sterile field below waist level
Correct Answer: A
Rationale: The nurse should turn away from the sterile field to sneeze or cough to
prevent contamination.
