RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT FORM
B ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES
Question 1
A nurse is providing discharge teaching to the parents of a newborn. Which instruction is
appropriate for umbilical cord care?
A) "Clean the cord stump with an alcohol wipe at each diaper change."
B) "Apply an antibiotic ointment to the cord stump daily to prevent infection."
C) "Submerge the cord stump in water during the bath to keep it clean."
D) "Keep the cord stump clean and dry, and fold the diaper down below it."
Correct Answer: D) "Keep the cord stump clean and dry, and fold the diaper down below
it."
Rationale: Current evidence-based practice is to keep the umbilical cord stump clean and
expose it to air as much as possible to allow it to dry and fall off naturally. Folding the
diaper down prevents contamination from urine and feces.
Question 2
A nurse is admitting a client to the hospital. According to the Patient Self-Determination Act,
which action should the nurse take?
A) Insist that the client complete an advance directive before receiving treatment.
B) Document in the medical record whether the client has an advance directive.
C) Explain that an advance directive cannot be changed once it is on file.
D) Witness the signing of the client's advance directive.
Correct Answer: B) Document in the medical record whether the client has an advance
directive.
Rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients
about the presence of an advance directive and to document this information in their
medical record.
Question 3
A nurse is providing a telehealth consultation for a client with a new diagnosis of diabetes.
Which action is appropriate for this type of service?
A) Performing a physical examination.
,B) Administering a dose of insulin.
C) Reinforcing teaching about how to check blood glucose levels.
D) Obtaining a blood sample for an HbA1c test.
Correct Answer: C) Reinforcing teaching about how to check blood glucose levels.
Rationale: Telehealth services are ideal for patient education, monitoring, and reinforcing
teaching. The nurse can use video technology to observe the client's technique and provide
corrective feedback.
Question 4
A nurse is providing dietary teaching to a client with type 2 diabetes. Which food choice is the
best example of a healthy carbohydrate?
A) A plain white bagel
B) A corn tortilla with black beans
C) A glass of orange juice
D) A bowl of frosted cereal
Correct Answer: B) A corn tortilla with black beans
Rationale: This option provides a complex carbohydrate (from the corn) combined with
fiber and protein (from the beans). This combination slows down glucose absorption and
provides a more stable blood sugar response compared to simple or refined carbohydrates.
Question 5
A nurse is teaching the parents of a preschooler with celiac disease. Which snack is an
appropriate choice?
A) Graham crackers with peanut butter
B) A cheese stick
C) A whole wheat pretzel
D) A bowl of oatmeal
Correct Answer: B) A cheese stick
Rationale: Celiac disease is an intolerance to gluten, a protein found in wheat, barley, and
rye. A cheese stick is naturally gluten-free and a good source of protein and calcium. The
other options all contain gluten.
,Question 6
A nurse is assessing a client for orthostatic hypotension. Which finding confirms this diagnosis?
A) A heart rate increase of 10 beats/min when standing.
B) A systolic blood pressure drop of 25 mm Hg upon standing.
C) A feeling of dizziness when changing position.
D) A diastolic blood pressure increase of 15 mm Hg upon standing.
Correct Answer: B) A systolic blood pressure drop of 25 mm Hg upon standing.
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20
mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within
three minutes of standing.
Question 7
A nurse is caring for a client on a mechanical ventilator, and the high-pressure alarm sounds.
What is the most likely cause?
A) The client has become disconnected from the ventilator.
B) There is a leak in the ventilator tubing.
C) The client needs to be suctioned due to airway obstruction.
D) The client is in respiratory arrest.
Correct Answer: C) The client needs to be suctioned due to airway obstruction.
Rationale: The high-pressure alarm indicates that the ventilator is meeting increased
resistance when trying to deliver a breath. Common causes include secretions in the airway,
the client coughing or biting the tube, or a kink in the tubing.
Question 8
A nurse is planning meals for a client with dysphagia following a stroke. Which food is the most
appropriate?
A) A piece of toast
B) A handful of nuts
C) Scrambled eggs
D) A glass of water
Correct Answer: C) Scrambled eggs
Rationale: Clients with dysphagia require foods with a soft, consistent texture that are easy
, to chew and swallow. Scrambled eggs are a good example of a food that would be included
in a mechanical soft or pureed diet.
Question 9
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the
sterile kit, what is the next step?
A) Don sterile gloves.
B) Clean the perineal area with antiseptic swabs.
C) Position the sterile drape, shiny side down, exposing the perineum.
D) Lubricate the tip of the catheter.
Correct Answer: C) Position the sterile drape, shiny side down, exposing the perineum.
Rationale: After opening the kit, the first step in setting up the sterile field is to place the
sterile drape. The shiny side is moisture-proof and is placed down, away from the sterile
field.
Question 10
A client receiving a blood transfusion develops chills, fever, low back pain, and chest tightness.
The nurse should suspect which type of reaction?
A) Allergic reaction
B) Febrile non-hemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Correct Answer: C) Acute hemolytic reaction
Rationale: These are the classic signs and symptoms of an acute hemolytic transfusion
reaction, a life-threatening emergency caused by ABO incompatibility. The reaction is
caused by the recipient's antibodies attacking the donor's red blood cells.
Question 11
A nurse is caring for a client in active labor who reports severe back pain. Which non-
pharmacological pain management technique is most effective?
A) Effleurage
B) Guided imagery
C) Application of counterpressure to the sacral area.
B ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES
Question 1
A nurse is providing discharge teaching to the parents of a newborn. Which instruction is
appropriate for umbilical cord care?
A) "Clean the cord stump with an alcohol wipe at each diaper change."
B) "Apply an antibiotic ointment to the cord stump daily to prevent infection."
C) "Submerge the cord stump in water during the bath to keep it clean."
D) "Keep the cord stump clean and dry, and fold the diaper down below it."
Correct Answer: D) "Keep the cord stump clean and dry, and fold the diaper down below
it."
Rationale: Current evidence-based practice is to keep the umbilical cord stump clean and
expose it to air as much as possible to allow it to dry and fall off naturally. Folding the
diaper down prevents contamination from urine and feces.
Question 2
A nurse is admitting a client to the hospital. According to the Patient Self-Determination Act,
which action should the nurse take?
A) Insist that the client complete an advance directive before receiving treatment.
B) Document in the medical record whether the client has an advance directive.
C) Explain that an advance directive cannot be changed once it is on file.
D) Witness the signing of the client's advance directive.
Correct Answer: B) Document in the medical record whether the client has an advance
directive.
Rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients
about the presence of an advance directive and to document this information in their
medical record.
Question 3
A nurse is providing a telehealth consultation for a client with a new diagnosis of diabetes.
Which action is appropriate for this type of service?
A) Performing a physical examination.
,B) Administering a dose of insulin.
C) Reinforcing teaching about how to check blood glucose levels.
D) Obtaining a blood sample for an HbA1c test.
Correct Answer: C) Reinforcing teaching about how to check blood glucose levels.
Rationale: Telehealth services are ideal for patient education, monitoring, and reinforcing
teaching. The nurse can use video technology to observe the client's technique and provide
corrective feedback.
Question 4
A nurse is providing dietary teaching to a client with type 2 diabetes. Which food choice is the
best example of a healthy carbohydrate?
A) A plain white bagel
B) A corn tortilla with black beans
C) A glass of orange juice
D) A bowl of frosted cereal
Correct Answer: B) A corn tortilla with black beans
Rationale: This option provides a complex carbohydrate (from the corn) combined with
fiber and protein (from the beans). This combination slows down glucose absorption and
provides a more stable blood sugar response compared to simple or refined carbohydrates.
Question 5
A nurse is teaching the parents of a preschooler with celiac disease. Which snack is an
appropriate choice?
A) Graham crackers with peanut butter
B) A cheese stick
C) A whole wheat pretzel
D) A bowl of oatmeal
Correct Answer: B) A cheese stick
Rationale: Celiac disease is an intolerance to gluten, a protein found in wheat, barley, and
rye. A cheese stick is naturally gluten-free and a good source of protein and calcium. The
other options all contain gluten.
,Question 6
A nurse is assessing a client for orthostatic hypotension. Which finding confirms this diagnosis?
A) A heart rate increase of 10 beats/min when standing.
B) A systolic blood pressure drop of 25 mm Hg upon standing.
C) A feeling of dizziness when changing position.
D) A diastolic blood pressure increase of 15 mm Hg upon standing.
Correct Answer: B) A systolic blood pressure drop of 25 mm Hg upon standing.
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20
mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within
three minutes of standing.
Question 7
A nurse is caring for a client on a mechanical ventilator, and the high-pressure alarm sounds.
What is the most likely cause?
A) The client has become disconnected from the ventilator.
B) There is a leak in the ventilator tubing.
C) The client needs to be suctioned due to airway obstruction.
D) The client is in respiratory arrest.
Correct Answer: C) The client needs to be suctioned due to airway obstruction.
Rationale: The high-pressure alarm indicates that the ventilator is meeting increased
resistance when trying to deliver a breath. Common causes include secretions in the airway,
the client coughing or biting the tube, or a kink in the tubing.
Question 8
A nurse is planning meals for a client with dysphagia following a stroke. Which food is the most
appropriate?
A) A piece of toast
B) A handful of nuts
C) Scrambled eggs
D) A glass of water
Correct Answer: C) Scrambled eggs
Rationale: Clients with dysphagia require foods with a soft, consistent texture that are easy
, to chew and swallow. Scrambled eggs are a good example of a food that would be included
in a mechanical soft or pureed diet.
Question 9
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the
sterile kit, what is the next step?
A) Don sterile gloves.
B) Clean the perineal area with antiseptic swabs.
C) Position the sterile drape, shiny side down, exposing the perineum.
D) Lubricate the tip of the catheter.
Correct Answer: C) Position the sterile drape, shiny side down, exposing the perineum.
Rationale: After opening the kit, the first step in setting up the sterile field is to place the
sterile drape. The shiny side is moisture-proof and is placed down, away from the sterile
field.
Question 10
A client receiving a blood transfusion develops chills, fever, low back pain, and chest tightness.
The nurse should suspect which type of reaction?
A) Allergic reaction
B) Febrile non-hemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Correct Answer: C) Acute hemolytic reaction
Rationale: These are the classic signs and symptoms of an acute hemolytic transfusion
reaction, a life-threatening emergency caused by ABO incompatibility. The reaction is
caused by the recipient's antibodies attacking the donor's red blood cells.
Question 11
A nurse is caring for a client in active labor who reports severe back pain. Which non-
pharmacological pain management technique is most effective?
A) Effleurage
B) Guided imagery
C) Application of counterpressure to the sacral area.
