2023
Capstone ATI RN
Proctored A Updated
2023
,a nurse is assessing the pain level of a client who has dementia and difficulty communicating,
which pain assessment technique should the nurse use?
behavioral indicators
(increased agitation, restlessness)
a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should
the nurse do first?
recheck the clients BP
(reassess prior to any intervention)
a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify
as a cath occlusion?
bladder distention
(inability to empty the bladder, impaired elimination)
a nurse is discussing immunity with a client who has received an immunization, the nurse
should identify that an immunization functions as part of which of the following types of
immunity?
acquired immunity
(artificial/acquired immunity occurs when antigens from toxoids or immunizations are
ADMINISTERED to a client, once in the body, the stimulate the production of antibodies)
a nurse is reviewing the health history of an OA who has a hip fracture
the nurse should identify what is a risk of developing pressure injuries?
urinary incontinence
(r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction
and shear, immobility, alterations in sensory perception)
a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red
and there is warmth along the coarse of the vein, what should the nurse do?
d/c the infusion
(assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start
new IV)
a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in
diameter. which of the following terms should the nurse use to document this finding?
macule
(nonpalpable smaller than 1cm, ex: freckle)
, a community health nurse is teaching a group of clients about first aid for different types of
wounds. which of the following client statements indicates an understanding of the teaching?
i should apply clean dressings over the top of blood saturated dressings and hold pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions
should the nurse take to facilitate mourning?
encourage the partner to ask for help when needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal
surgery. which of the following behaviors should the nurse identify as increasing the client's risk
for constipation?
urge suppression
history of chronic stimulant laxative use
inadequate fluid intake
a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the
nurse do?
ask the client to describe feelings
a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound.
which of the following actions should the nurse take to prevent contamination during the
dressing change?
restart the procedure if the sterile solution splashes onto the sterile field when pouring the
solution into the dressing tray
(if liquid comes in contact with the sterile field at any point it is considered contaminated and
unsterile)
a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just
fine and have decided to cancel my surgery". which of the following responses should the nurse
make?
share with me more about the thoughts that are concerning you
a nurse is teaching a client about the use of a MDI, which instruction should the nurse include
in the teaching?
inhale the medication deeply for 3-5seconds
(hold breath for 10s after inhalation, shake MDI vigorously, hold mouthpiece 2.5-5cm/1-2in in
front of mouth)
Capstone ATI RN
Proctored A Updated
2023
,a nurse is assessing the pain level of a client who has dementia and difficulty communicating,
which pain assessment technique should the nurse use?
behavioral indicators
(increased agitation, restlessness)
a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should
the nurse do first?
recheck the clients BP
(reassess prior to any intervention)
a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify
as a cath occlusion?
bladder distention
(inability to empty the bladder, impaired elimination)
a nurse is discussing immunity with a client who has received an immunization, the nurse
should identify that an immunization functions as part of which of the following types of
immunity?
acquired immunity
(artificial/acquired immunity occurs when antigens from toxoids or immunizations are
ADMINISTERED to a client, once in the body, the stimulate the production of antibodies)
a nurse is reviewing the health history of an OA who has a hip fracture
the nurse should identify what is a risk of developing pressure injuries?
urinary incontinence
(r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction
and shear, immobility, alterations in sensory perception)
a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red
and there is warmth along the coarse of the vein, what should the nurse do?
d/c the infusion
(assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start
new IV)
a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in
diameter. which of the following terms should the nurse use to document this finding?
macule
(nonpalpable smaller than 1cm, ex: freckle)
, a community health nurse is teaching a group of clients about first aid for different types of
wounds. which of the following client statements indicates an understanding of the teaching?
i should apply clean dressings over the top of blood saturated dressings and hold pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions
should the nurse take to facilitate mourning?
encourage the partner to ask for help when needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal
surgery. which of the following behaviors should the nurse identify as increasing the client's risk
for constipation?
urge suppression
history of chronic stimulant laxative use
inadequate fluid intake
a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the
nurse do?
ask the client to describe feelings
a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound.
which of the following actions should the nurse take to prevent contamination during the
dressing change?
restart the procedure if the sterile solution splashes onto the sterile field when pouring the
solution into the dressing tray
(if liquid comes in contact with the sterile field at any point it is considered contaminated and
unsterile)
a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just
fine and have decided to cancel my surgery". which of the following responses should the nurse
make?
share with me more about the thoughts that are concerning you
a nurse is teaching a client about the use of a MDI, which instruction should the nurse include
in the teaching?
inhale the medication deeply for 3-5seconds
(hold breath for 10s after inhalation, shake MDI vigorously, hold mouthpiece 2.5-5cm/1-2in in
front of mouth)
