RN ATI Capstone Proctored Comprehensive Assessment 2025 A/ ATI Comprehensive
2025 A| Answers And Rationale- Complete Test Bank (180 Questions)
1. A client with chronic obstructive pulmonary disease (COPD) has oxygen prescribed at 2
L/min via nasal cannula. The client reports increased shortness of breath. What is the
nurse’s best first action?
Answer: C — Assess respiratory status (rate, depth, breath sounds, O₂
saturation).
Rationale: Always assess before changing therapy; evaluate for causes of increased
dyspnea (e.g., infection, pneumothorax, device dislodgement).
2. A postoperative client has received morphine 4 mg IV 30 minutes ago and now is drowsy
with respiratory rate 8/min. Which action is highest priority?
Answer: A — Stimulate the client and call for naloxone if respiratory depression
persists.
Rationale: Opioid-induced respiratory depression is life-threatening; stimulate,
administer oxygen, and prepare naloxone per protocol.
3. A client with heart failure has a new prescription for furosemide (Lasix). Which lab should
the nurse monitor closely?
Answer: B — Serum potassium.
Rationale: Loop diuretics cause potassium loss; monitor for hypokalemia which
increases arrhythmia risk.
4. A mother asks why her newborn has a yellowish color on day 3. The nurse explains
physiologic jaundice. Which statement is correct?
Answer: D — It’s common after 24 hours as bilirubin rises and usually resolves in
1–2 weeks.
Rationale: Physiologic newborn jaundice appears after first 24 hours due to immature
bilirubin conjugation.
5. A client admitted with diabetic ketoacidosis (DKA) has K+ 3.1 mEq/L. What should the
nurse anticipate?
Answer: B — Replace potassium after initiating insulin therapy and monitoring.
Rationale: Insulin shifts potassium intracellularly; low K+ must be corrected to prevent
arrhythmia before insulin lowers serum K+ further.
6. Which action by a nurse best reduces risk of central line–associated bloodstream
infection (CLABSI)?
Answer: A — Perform chlorhexidine scrub and sterile dressing changes per
, protocol.
Rationale: Proper central line care and sterile technique prevent CLABSI.
7. A client with schizophrenia is started on haloperidol. Which side effect requires
immediate intervention?
Answer: C — High fever, muscle rigidity, altered mental status (possible
neuroleptic malignant syndrome).
Rationale: NMS is a life-threatening reaction; stop medication and treat emergently.
8. A nurse prepares to administer IV vancomycin. Which is most important to monitor
during infusion?
Answer: D — Red man syndrome signs (flushing, hypotension); infuse slowly.
Rationale: Rapid infusion can cause histamine-mediated reaction; slow infusion and
monitor vitals.
9. A child with acute asthma is using albuterol nebulizer. Which symptom indicates effective
treatment?
Answer: B — Decreased wheezing and improved oxygen saturation.
Rationale: Bronchodilation should improve air flow and oxygenation.
10.A pregnant client at 34 weeks reports decreased fetal movement. What is the nurse’s
best initial action?
Answer: A — Perform a nonstress test (NST) or fetal movement assessment per
protocol.
Rationale: Decreased fetal movement can signal fetal compromise; assess fetal
well-being promptly.
11.A client on warfarin (Coumadin) has INR 5.0 and minor bleeding. What should nurse
expect?
Answer: B — Hold warfarin and administer vitamin K per provider order.
Rationale: High INR increases bleeding risk; vitamin K reverses effects. Management
depends on severity.
12.A nurse is teaching a client about metformin. Which instruction is important?
Answer: C — Take with meals to reduce GI upset and avoid alcohol to decrease
lactic acidosis risk.
Rationale: Metformin can cause GI effects and rare lactic acidosis; alcohol increases
risk.
13.A client with acute pancreatitis reports severe epigastric pain and has low-grade fever.
Which lab is most closely associated with diagnosis?
Answer: A — Elevated serum amylase and lipase.
Rationale: Amylase and lipase rise with pancreatic inflammation; lipase is more
, specific.
14.A nurse observes another staff member fail to perform hand hygiene between clients.
What is the nurse’s best action?
Answer: D — Remind the staff member privately and report per facility policy if
repeated.
Rationale: Addressing immediately reduces infection risk and follows professional
accountability.
15.Which intervention is priority for a client with suspected stroke within the first hour?
Answer: B — Obtain CT scan to determine ischemic vs hemorrhagic stroke.
Rationale: CT distinguishes hemorrhage; thrombolytic therapy timing depends on
stroke type.
16.A client with chronic kidney disease (CKD) complains of fatigue and pallor. Which lab
result best explains this?
Answer: C — Low hemoglobin due to decreased erythropoietin production.
Rationale: CKD causes anemia from decreased erythropoietin; treat with
erythropoiesis-stimulating agents as ordered.
17.A nurse administers insulin lispro at 0800 with breakfast. Which assessment is most
important 30–60 minutes later?
Answer: A — Monitor for hypoglycemia (sweating, pallor, confusion).
Rationale: Rapid-acting insulin peaks soon after administration; watch for low glucose.
18.Which action should the nurse take for a client having a tonic-clonic seizure?
Answer: B — Protect head, clear surrounding objects, maintain airway, do not
restrain.
Rationale: Ensure safety and airway; do not place objects in mouth.
19.A client with peripheral arterial disease (PAD) should be taught to:
Answer: C — Elevate feet slightly but avoid prolonged dependency and avoid
crossing legs.
Rationale: Avoid dependent positioning causing increased pain; promote circulation
without extreme elevation.
20.A client receiving gentamicin is scheduled for discharge. Which teaching is essential?
Answer: D — Report any hearing changes immediately (risk of ototoxicity).
Rationale: Aminoglycosides can cause ototoxicity; early detection is critical.
21.A postop client has sudden chest pain, tachycardia, and shortness of breath—suspected
pulmonary embolism (PE). First nursing action?
Answer: A — Notify provider and prepare to administer oxygen and
anticoagulation per protocol.
2025 A| Answers And Rationale- Complete Test Bank (180 Questions)
1. A client with chronic obstructive pulmonary disease (COPD) has oxygen prescribed at 2
L/min via nasal cannula. The client reports increased shortness of breath. What is the
nurse’s best first action?
Answer: C — Assess respiratory status (rate, depth, breath sounds, O₂
saturation).
Rationale: Always assess before changing therapy; evaluate for causes of increased
dyspnea (e.g., infection, pneumothorax, device dislodgement).
2. A postoperative client has received morphine 4 mg IV 30 minutes ago and now is drowsy
with respiratory rate 8/min. Which action is highest priority?
Answer: A — Stimulate the client and call for naloxone if respiratory depression
persists.
Rationale: Opioid-induced respiratory depression is life-threatening; stimulate,
administer oxygen, and prepare naloxone per protocol.
3. A client with heart failure has a new prescription for furosemide (Lasix). Which lab should
the nurse monitor closely?
Answer: B — Serum potassium.
Rationale: Loop diuretics cause potassium loss; monitor for hypokalemia which
increases arrhythmia risk.
4. A mother asks why her newborn has a yellowish color on day 3. The nurse explains
physiologic jaundice. Which statement is correct?
Answer: D — It’s common after 24 hours as bilirubin rises and usually resolves in
1–2 weeks.
Rationale: Physiologic newborn jaundice appears after first 24 hours due to immature
bilirubin conjugation.
5. A client admitted with diabetic ketoacidosis (DKA) has K+ 3.1 mEq/L. What should the
nurse anticipate?
Answer: B — Replace potassium after initiating insulin therapy and monitoring.
Rationale: Insulin shifts potassium intracellularly; low K+ must be corrected to prevent
arrhythmia before insulin lowers serum K+ further.
6. Which action by a nurse best reduces risk of central line–associated bloodstream
infection (CLABSI)?
Answer: A — Perform chlorhexidine scrub and sterile dressing changes per
, protocol.
Rationale: Proper central line care and sterile technique prevent CLABSI.
7. A client with schizophrenia is started on haloperidol. Which side effect requires
immediate intervention?
Answer: C — High fever, muscle rigidity, altered mental status (possible
neuroleptic malignant syndrome).
Rationale: NMS is a life-threatening reaction; stop medication and treat emergently.
8. A nurse prepares to administer IV vancomycin. Which is most important to monitor
during infusion?
Answer: D — Red man syndrome signs (flushing, hypotension); infuse slowly.
Rationale: Rapid infusion can cause histamine-mediated reaction; slow infusion and
monitor vitals.
9. A child with acute asthma is using albuterol nebulizer. Which symptom indicates effective
treatment?
Answer: B — Decreased wheezing and improved oxygen saturation.
Rationale: Bronchodilation should improve air flow and oxygenation.
10.A pregnant client at 34 weeks reports decreased fetal movement. What is the nurse’s
best initial action?
Answer: A — Perform a nonstress test (NST) or fetal movement assessment per
protocol.
Rationale: Decreased fetal movement can signal fetal compromise; assess fetal
well-being promptly.
11.A client on warfarin (Coumadin) has INR 5.0 and minor bleeding. What should nurse
expect?
Answer: B — Hold warfarin and administer vitamin K per provider order.
Rationale: High INR increases bleeding risk; vitamin K reverses effects. Management
depends on severity.
12.A nurse is teaching a client about metformin. Which instruction is important?
Answer: C — Take with meals to reduce GI upset and avoid alcohol to decrease
lactic acidosis risk.
Rationale: Metformin can cause GI effects and rare lactic acidosis; alcohol increases
risk.
13.A client with acute pancreatitis reports severe epigastric pain and has low-grade fever.
Which lab is most closely associated with diagnosis?
Answer: A — Elevated serum amylase and lipase.
Rationale: Amylase and lipase rise with pancreatic inflammation; lipase is more
, specific.
14.A nurse observes another staff member fail to perform hand hygiene between clients.
What is the nurse’s best action?
Answer: D — Remind the staff member privately and report per facility policy if
repeated.
Rationale: Addressing immediately reduces infection risk and follows professional
accountability.
15.Which intervention is priority for a client with suspected stroke within the first hour?
Answer: B — Obtain CT scan to determine ischemic vs hemorrhagic stroke.
Rationale: CT distinguishes hemorrhage; thrombolytic therapy timing depends on
stroke type.
16.A client with chronic kidney disease (CKD) complains of fatigue and pallor. Which lab
result best explains this?
Answer: C — Low hemoglobin due to decreased erythropoietin production.
Rationale: CKD causes anemia from decreased erythropoietin; treat with
erythropoiesis-stimulating agents as ordered.
17.A nurse administers insulin lispro at 0800 with breakfast. Which assessment is most
important 30–60 minutes later?
Answer: A — Monitor for hypoglycemia (sweating, pallor, confusion).
Rationale: Rapid-acting insulin peaks soon after administration; watch for low glucose.
18.Which action should the nurse take for a client having a tonic-clonic seizure?
Answer: B — Protect head, clear surrounding objects, maintain airway, do not
restrain.
Rationale: Ensure safety and airway; do not place objects in mouth.
19.A client with peripheral arterial disease (PAD) should be taught to:
Answer: C — Elevate feet slightly but avoid prolonged dependency and avoid
crossing legs.
Rationale: Avoid dependent positioning causing increased pain; promote circulation
without extreme elevation.
20.A client receiving gentamicin is scheduled for discharge. Which teaching is essential?
Answer: D — Report any hearing changes immediately (risk of ototoxicity).
Rationale: Aminoglycosides can cause ototoxicity; early detection is critical.
21.A postop client has sudden chest pain, tachycardia, and shortness of breath—suspected
pulmonary embolism (PE). First nursing action?
Answer: A — Notify provider and prepare to administer oxygen and
anticoagulation per protocol.
