ATI RN Capstone Proctored Post-
Assessment: 100 Practice Questions With
Answers and Rationales
Section 1: Fundamentals, Safety, and Infection Control
Question 1
A nurse is caring for a client who has Clostridioides difficile infection. Which infection-
control measure should the nurse implement?
A. Use alcohol-based hand sanitizer after client care. B. Wear a surgical mask when
entering the room. C. Wash hands with soap and water after client care. D. Place the
client in a positive-pressure room.
Correct answer: C. Wash hands with soap and water after client care.
Rationale: C. difficile produces spores that are not reliably removed by alcohol-based
hand sanitizers. Soap and water mechanically remove spores. Contact precautions and
appropriate environmental disinfection are also necessary.
Question 2
A nurse discovers a fire in a client's room. Which action should the nurse take first?
A. Activate the fire alarm. B. Remove the client from immediate danger. C. Close all unit
doors. D. Obtain a fire extinguisher.
Correct answer: B. Remove the client from immediate danger.
Rationale: The RACE fire-response sequence begins with Rescue clients in immediate
danger, followed by Alarm, Contain, and Extinguish or Evacuate as appropriate.
Question 3
A nurse is preparing to administer medication to a client. Which action best supports
medication safety?
A. Prepare medications for several clients at once. B. Identify the client using their room
number. C. Verify the client's identity using two approved identifiers. D. Ask another
client to confirm the client's name.
Correct answer: C. Verify the client's identity using two approved identifiers.
Rationale: Two approved identifiers, such as the client's full name and date of birth,
reduce medication-administration errors. Room numbers are not acceptable identifiers.
,Question 4
A nurse is caring for a client who has a seizure. Which action should the nurse take?
A. Insert a padded tongue blade into the mouth. B. Restrain the client's extremities. C.
Turn the client onto their side when feasible. D. Offer water immediately after the
seizure begins.
Correct answer: C. Turn the client onto their side when feasible.
Rationale: Side positioning helps maintain the airway and allows secretions to drain.
The nurse should protect the client from injury, time the seizure, and never restrain the
client or place objects in their mouth.
Question 5
A nurse is caring for a client with suspected pulmonary tuberculosis. Which precaution is
appropriate?
A. Contact precautions in a positive-pressure room. B. Airborne precautions in an
airborne infection isolation room. C. Droplet precautions with a surgical mask only. D.
Standard precautions without respiratory protection.
Correct answer: B. Airborne precautions in an airborne infection isolation room.
Rationale: Pulmonary tuberculosis spreads through airborne particles. The client should
be placed in an appropriately ventilated negative-pressure room, and staff should use a
fit-tested N95 respirator or equivalent protection.
Question 6
A nurse is preparing to transfer a weak client from the bed to a chair. Which action is
safest?
A. Ask the client to hold the nurse's neck. B. Keep the nurse's feet together during the
transfer. C. Use a gait belt when appropriate and assess the client's ability to bear
weight. D. Pull the client upward by the arms.
Correct answer: C. Use a gait belt when appropriate and assess the client's ability
to bear weight.
Rationale: Assessing mobility and using appropriate transfer equipment reduces fall
and musculoskeletal injury risk. The nurse should use a stable base of support and avoid
pulling on the client's arms or neck.
Question 7
A nurse receives a prescription for a medication that the nurse believes is unsafe for the
client. What should the nurse do?
,A. Administer the medication because the provider prescribed it. B. Withhold the
medication temporarily and clarify the prescription. C. Ask the client's family to decide
whether to administer it. D. Document the concern and administer the medication.
Correct answer: B. Withhold the medication temporarily and clarify the
prescription.
Rationale: Nurses are accountable for safe medication administration. An unclear or
potentially harmful prescription must be clarified before administration.
Question 8
A nurse is caring for a client who is at risk for falls. Which intervention is appropriate?
A. Keep the bed in its lowest position with the brakes locked. B. Keep all four side rails
raised at all times. C. Place the call light out of reach to prevent unnecessary movement.
D. Encourage the client to walk independently when dizzy.
Correct answer: A. Keep the bed in its lowest position with the brakes locked.
Rationale: A low, locked bed, accessible call light, adequate lighting, nonskid footwear,
and individualized assistance reduce fall risk. Raising all four side rails may constitute a
restraint and can increase injury risk.
Question 9
A nurse is preparing to provide wound care using sterile technique. Which action
contaminates a sterile field?
A. Keeping the sterile field above waist level. B. Opening the first sterile package flap
away from the body. C. Reaching across the sterile field with an unsterile arm. D.
Keeping the sterile field in view.
Correct answer: C. Reaching across the sterile field with an unsterile arm.
Rationale: Reaching over a sterile field risks contamination from the nurse's clothing or
arms. Sterile items must remain within the sterile field, and any item of questionable
sterility should be considered contaminated.
Question 10
A nurse is caring for a client who has a new prescription for restraints because of
repeated attempts to remove essential treatment devices. Which action is appropriate?
A. Apply restraints without assessing other options. B. Use restraints as punishment for
noncompliance. C. Try less restrictive alternatives and follow applicable restraint orders
and monitoring requirements. D. Tie the restraints to the side rails.
Correct answer: C. Try less restrictive alternatives and follow applicable restraint
orders and monitoring requirements.
, Rationale: Restraints are a last resort, not a punishment or convenience. The nurse
should attempt alternatives, use the least restrictive effective intervention, follow
applicable laws and facility policies, and monitor the client's safety and circulation.
Section 2: Medical-Surgical Nursing
Question 11
A nurse assesses a client who has heart failure. Which finding requires the most
immediate follow-up?
A. Mild ankle edema at the end of the day. B. Sudden shortness of breath with crackles
and pink, frothy sputum. C. Fatigue after walking a long distance. D. A 0.2 kg weight
increase over one week.
Correct answer: B. Sudden shortness of breath with crackles and pink, frothy
sputum.
Rationale: These findings suggest acute pulmonary edema, a potentially life-
threatening complication of heart failure. The nurse should promptly support
oxygenation, activate emergency assistance as indicated, and anticipate urgent
treatment.
Question 12
A client with diabetes mellitus is awake, sweating, trembling, and has a blood glucose
level of 54 mg/dL. What should the nurse do first?
A. Administer the scheduled insulin. B. Give approximately 15 g of fast-acting
carbohydrate. C. Encourage the client to exercise. D. Restrict oral intake.
Correct answer: B. Give approximately 15 g of fast-acting carbohydrate.
Rationale: A conscious client who can swallow safely should receive about 15 g of fast-
acting carbohydrate. Recheck blood glucose after 15 minutes and repeat treatment if it
remains below 70 mg/dL. Severe hypoglycemia with impaired consciousness requires a
different emergency approach.
Question 13
A nurse is caring for a client with chronic obstructive pulmonary disease who is
experiencing an exacerbation. Which action is appropriate?
A. Withhold oxygen under all circumstances. B. Administer prescribed oxygen and titrate
to the target saturation. C. Encourage prolonged breath-holding. D. Place the client flat
in bed.
Correct answer: B. Administer prescribed oxygen and titrate to the target
saturation.
Assessment: 100 Practice Questions With
Answers and Rationales
Section 1: Fundamentals, Safety, and Infection Control
Question 1
A nurse is caring for a client who has Clostridioides difficile infection. Which infection-
control measure should the nurse implement?
A. Use alcohol-based hand sanitizer after client care. B. Wear a surgical mask when
entering the room. C. Wash hands with soap and water after client care. D. Place the
client in a positive-pressure room.
Correct answer: C. Wash hands with soap and water after client care.
Rationale: C. difficile produces spores that are not reliably removed by alcohol-based
hand sanitizers. Soap and water mechanically remove spores. Contact precautions and
appropriate environmental disinfection are also necessary.
Question 2
A nurse discovers a fire in a client's room. Which action should the nurse take first?
A. Activate the fire alarm. B. Remove the client from immediate danger. C. Close all unit
doors. D. Obtain a fire extinguisher.
Correct answer: B. Remove the client from immediate danger.
Rationale: The RACE fire-response sequence begins with Rescue clients in immediate
danger, followed by Alarm, Contain, and Extinguish or Evacuate as appropriate.
Question 3
A nurse is preparing to administer medication to a client. Which action best supports
medication safety?
A. Prepare medications for several clients at once. B. Identify the client using their room
number. C. Verify the client's identity using two approved identifiers. D. Ask another
client to confirm the client's name.
Correct answer: C. Verify the client's identity using two approved identifiers.
Rationale: Two approved identifiers, such as the client's full name and date of birth,
reduce medication-administration errors. Room numbers are not acceptable identifiers.
,Question 4
A nurse is caring for a client who has a seizure. Which action should the nurse take?
A. Insert a padded tongue blade into the mouth. B. Restrain the client's extremities. C.
Turn the client onto their side when feasible. D. Offer water immediately after the
seizure begins.
Correct answer: C. Turn the client onto their side when feasible.
Rationale: Side positioning helps maintain the airway and allows secretions to drain.
The nurse should protect the client from injury, time the seizure, and never restrain the
client or place objects in their mouth.
Question 5
A nurse is caring for a client with suspected pulmonary tuberculosis. Which precaution is
appropriate?
A. Contact precautions in a positive-pressure room. B. Airborne precautions in an
airborne infection isolation room. C. Droplet precautions with a surgical mask only. D.
Standard precautions without respiratory protection.
Correct answer: B. Airborne precautions in an airborne infection isolation room.
Rationale: Pulmonary tuberculosis spreads through airborne particles. The client should
be placed in an appropriately ventilated negative-pressure room, and staff should use a
fit-tested N95 respirator or equivalent protection.
Question 6
A nurse is preparing to transfer a weak client from the bed to a chair. Which action is
safest?
A. Ask the client to hold the nurse's neck. B. Keep the nurse's feet together during the
transfer. C. Use a gait belt when appropriate and assess the client's ability to bear
weight. D. Pull the client upward by the arms.
Correct answer: C. Use a gait belt when appropriate and assess the client's ability
to bear weight.
Rationale: Assessing mobility and using appropriate transfer equipment reduces fall
and musculoskeletal injury risk. The nurse should use a stable base of support and avoid
pulling on the client's arms or neck.
Question 7
A nurse receives a prescription for a medication that the nurse believes is unsafe for the
client. What should the nurse do?
,A. Administer the medication because the provider prescribed it. B. Withhold the
medication temporarily and clarify the prescription. C. Ask the client's family to decide
whether to administer it. D. Document the concern and administer the medication.
Correct answer: B. Withhold the medication temporarily and clarify the
prescription.
Rationale: Nurses are accountable for safe medication administration. An unclear or
potentially harmful prescription must be clarified before administration.
Question 8
A nurse is caring for a client who is at risk for falls. Which intervention is appropriate?
A. Keep the bed in its lowest position with the brakes locked. B. Keep all four side rails
raised at all times. C. Place the call light out of reach to prevent unnecessary movement.
D. Encourage the client to walk independently when dizzy.
Correct answer: A. Keep the bed in its lowest position with the brakes locked.
Rationale: A low, locked bed, accessible call light, adequate lighting, nonskid footwear,
and individualized assistance reduce fall risk. Raising all four side rails may constitute a
restraint and can increase injury risk.
Question 9
A nurse is preparing to provide wound care using sterile technique. Which action
contaminates a sterile field?
A. Keeping the sterile field above waist level. B. Opening the first sterile package flap
away from the body. C. Reaching across the sterile field with an unsterile arm. D.
Keeping the sterile field in view.
Correct answer: C. Reaching across the sterile field with an unsterile arm.
Rationale: Reaching over a sterile field risks contamination from the nurse's clothing or
arms. Sterile items must remain within the sterile field, and any item of questionable
sterility should be considered contaminated.
Question 10
A nurse is caring for a client who has a new prescription for restraints because of
repeated attempts to remove essential treatment devices. Which action is appropriate?
A. Apply restraints without assessing other options. B. Use restraints as punishment for
noncompliance. C. Try less restrictive alternatives and follow applicable restraint orders
and monitoring requirements. D. Tie the restraints to the side rails.
Correct answer: C. Try less restrictive alternatives and follow applicable restraint
orders and monitoring requirements.
, Rationale: Restraints are a last resort, not a punishment or convenience. The nurse
should attempt alternatives, use the least restrictive effective intervention, follow
applicable laws and facility policies, and monitor the client's safety and circulation.
Section 2: Medical-Surgical Nursing
Question 11
A nurse assesses a client who has heart failure. Which finding requires the most
immediate follow-up?
A. Mild ankle edema at the end of the day. B. Sudden shortness of breath with crackles
and pink, frothy sputum. C. Fatigue after walking a long distance. D. A 0.2 kg weight
increase over one week.
Correct answer: B. Sudden shortness of breath with crackles and pink, frothy
sputum.
Rationale: These findings suggest acute pulmonary edema, a potentially life-
threatening complication of heart failure. The nurse should promptly support
oxygenation, activate emergency assistance as indicated, and anticipate urgent
treatment.
Question 12
A client with diabetes mellitus is awake, sweating, trembling, and has a blood glucose
level of 54 mg/dL. What should the nurse do first?
A. Administer the scheduled insulin. B. Give approximately 15 g of fast-acting
carbohydrate. C. Encourage the client to exercise. D. Restrict oral intake.
Correct answer: B. Give approximately 15 g of fast-acting carbohydrate.
Rationale: A conscious client who can swallow safely should receive about 15 g of fast-
acting carbohydrate. Recheck blood glucose after 15 minutes and repeat treatment if it
remains below 70 mg/dL. Severe hypoglycemia with impaired consciousness requires a
different emergency approach.
Question 13
A nurse is caring for a client with chronic obstructive pulmonary disease who is
experiencing an exacerbation. Which action is appropriate?
A. Withhold oxygen under all circumstances. B. Administer prescribed oxygen and titrate
to the target saturation. C. Encourage prolonged breath-holding. D. Place the client flat
in bed.
Correct answer: B. Administer prescribed oxygen and titrate to the target
saturation.
