ATI CAPSTONE COMPREHENSIVE ASSESSMENT A COMPLETE ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS/ GRADE A+ ASSURED(REAL
DEAL)
Question 1
A nurse is admitting a client who has suicidal ideations. Which of the following is the priority
nursing action?
A) Allow the client to keep personal hygiene items.
B) Ensure the client's hands are visible when sleeping.
C) Search the client's belongings with the client present.
D) Assign the client to a private room.
Correct Answer: C) Search the client's belongings with the client present.
Rationale: The immediate priority for a client with suicidal ideations is to create a safe
environment. This begins by searching the client's belongings to remove any potentially
harmful items. Involving the client in the search is respectful and helps build therapeutic
trust.
Question 2
A nurse is caring for a client who is immunosuppressed. Which of the following is an essential
assessment to monitor for infection?
A) Monitoring daily weight.
B) Inspecting skin and mucous membranes for breakdown.
C) Assessing for pitting edema.
D) Checking for peripheral pulses.
Correct Answer: B) Inspecting skin and mucous membranes for breakdown.
Rationale: The skin and mucous membranes are the body's first line of defense against
infection. Immunosuppressed clients are at high risk, and any break in this barrier (fissures,
breakdown, abscess) can be a portal of entry for pathogens.
Question 3
Which system offers a clear, standardized structure for disaster management at the facility
level?
A) The Centers for Disease Control and Prevention (CDC).
,B) The Hospital Incident Command System (HICS).
C) The Federal Emergency Management Agency (FEMA).
D) The National Institutes of Health (NIH).
Correct Answer: B) The Hospital Incident Command System (HICS).
Rationale: HICS is an emergency management system that provides a standardized
organizational structure for hospitals to manage incidents and disasters, ensuring clear lines
of authority and communication.
Question 4
A nurse in a community clinic diagnoses a client with tuberculosis (TB). What is the nurse's legal
responsibility regarding this diagnosis?
A) Immediately begin contact tracing of the client's family.
B) Report the diagnosis to the proper public health agency.
C) Educate the client on the importance of medication adherence.
D) Isolate the client in a negative-pressure room.
Correct Answer: B) Report the diagnosis to the proper public health agency.
Rationale: Nurses are mandated reporters for specific communicable diseases as defined by
state and federal laws. Tuberculosis is a nationally notifiable disease that must be reported to
the local or state health department to allow for public health surveillance and intervention.
Question 5
A client with diabetes mellitus reports numbness and pain in their feet. The nurse recognizes
this as a manifestation of which long-term complication?
A) Autonomic neuropathy
B) Peripheral neuropathy
C) Nephropathy
D) Retinopathy
Correct Answer: B) Peripheral neuropathy
Rationale: Peripheral neuropathy is caused by damage to sensory nerve fibers, which results
in symptoms such as numbness, tingling, pain, and burning, typically in the hands and feet.
,Question 6
A nurse is monitoring a client who is taking risperidone. Which of the following findings should
the nurse identify as a potential adverse effect requiring intervention?
A) Increased heart rate upon standing.
B) A report of dry mouth.
C) A weight gain of 2 pounds in a week.
D) Dizziness when changing from a sitting to a standing position.
Correct Answer: D) Dizziness when changing from a sitting to a standing position.
Rationale: Risperidone, an atypical antipsychotic, can cause orthostatic hypotension. The
nurse should monitor the client's blood pressure for orthostatic changes and instruct the
client to change positions slowly to prevent dizziness and falls.
Question 7
When preparing for a sterile dressing change, which of the following actions demonstrates a
breach in sterile technique?
A) Opening the sterile pack away from the body.
B) Keeping the sterile field above waist level.
C) Pouring sterile solution into a basin on the sterile field.
D) Turning their back to the sterile field to retrieve an item.
Correct Answer: D) Turning their back to the sterile field to retrieve an item.
Rationale: A sterile field is considered contaminated if it is out of the clinician's line of sight.
One must never turn their back on a sterile field.
Question 8
A nurse is teaching a parent about car seat safety for their 18-month-old toddler. Which of the
following statements indicates the parent understands the teaching?
A) "I will place the car seat in a forward-facing position in the back seat."
B) "My toddler should remain in a rear-facing car seat until age 2."
C) "I can place the car seat in the front passenger seat if the airbag is off."
D) "The retainer clip should be placed at the level of the belly button."
Correct Answer: B) "My toddler should remain in a rear-facing car seat until age 2."
, Rationale: Current safety guidelines from the American Academy of Pediatrics recommend
that infants and toddlers remain in a rear-facing car seat until they are at least 2 years of age
or until they reach the highest weight or height allowed by their car seat's manufacturer.
Question 9
A staff nurse is educating a group of newly licensed nurses about organ donation. Which of the
following statements should be included in the teaching?
A) "Any licensed nurse can approach the family to request organ donation."
B) "Organ donation requests should be made by specially trained personnel."
C) "Once a client is declared brain dead, cardiovascular support should be discontinued."
D) "Family discussions about donation should take place in the client's room."
Correct Answer: B) "Organ donation requests should be made by specially trained personnel."
Rationale: The process of requesting organ and tissue donation is a sensitive and complex
conversation that must be handled by personnel who have received specific training (often
from an organ procurement organization) to be effective and supportive.
Question 10
A nurse manager is observing a newly licensed nurse moving a client up in bed. Which of the
following actions by the newly licensed nurse indicates a need for further teaching?
A) Bending at the waist to pull the client up.
B) Raising the bed to a comfortable working height.
C) Asking another staff member for assistance.
D) Using a smooth movement to reposition the client.
Correct Answer: A) Bending at the waist to pull the client up.
Rationale: Bending at the waist (flexion of the spine) places significant strain on the lower
back and increases the risk of injury. Proper body mechanics involve bending at the knees and
hips while keeping the back straight.
Question 11
A child with cystic fibrosis is prescribed therapy with a high-frequency chest compression vest.
The nurse should explain to the parents that the purpose of this device is to:
QUESTIONS AND CORRECT DETAILED ANSWERS/ GRADE A+ ASSURED(REAL
DEAL)
Question 1
A nurse is admitting a client who has suicidal ideations. Which of the following is the priority
nursing action?
A) Allow the client to keep personal hygiene items.
B) Ensure the client's hands are visible when sleeping.
C) Search the client's belongings with the client present.
D) Assign the client to a private room.
Correct Answer: C) Search the client's belongings with the client present.
Rationale: The immediate priority for a client with suicidal ideations is to create a safe
environment. This begins by searching the client's belongings to remove any potentially
harmful items. Involving the client in the search is respectful and helps build therapeutic
trust.
Question 2
A nurse is caring for a client who is immunosuppressed. Which of the following is an essential
assessment to monitor for infection?
A) Monitoring daily weight.
B) Inspecting skin and mucous membranes for breakdown.
C) Assessing for pitting edema.
D) Checking for peripheral pulses.
Correct Answer: B) Inspecting skin and mucous membranes for breakdown.
Rationale: The skin and mucous membranes are the body's first line of defense against
infection. Immunosuppressed clients are at high risk, and any break in this barrier (fissures,
breakdown, abscess) can be a portal of entry for pathogens.
Question 3
Which system offers a clear, standardized structure for disaster management at the facility
level?
A) The Centers for Disease Control and Prevention (CDC).
,B) The Hospital Incident Command System (HICS).
C) The Federal Emergency Management Agency (FEMA).
D) The National Institutes of Health (NIH).
Correct Answer: B) The Hospital Incident Command System (HICS).
Rationale: HICS is an emergency management system that provides a standardized
organizational structure for hospitals to manage incidents and disasters, ensuring clear lines
of authority and communication.
Question 4
A nurse in a community clinic diagnoses a client with tuberculosis (TB). What is the nurse's legal
responsibility regarding this diagnosis?
A) Immediately begin contact tracing of the client's family.
B) Report the diagnosis to the proper public health agency.
C) Educate the client on the importance of medication adherence.
D) Isolate the client in a negative-pressure room.
Correct Answer: B) Report the diagnosis to the proper public health agency.
Rationale: Nurses are mandated reporters for specific communicable diseases as defined by
state and federal laws. Tuberculosis is a nationally notifiable disease that must be reported to
the local or state health department to allow for public health surveillance and intervention.
Question 5
A client with diabetes mellitus reports numbness and pain in their feet. The nurse recognizes
this as a manifestation of which long-term complication?
A) Autonomic neuropathy
B) Peripheral neuropathy
C) Nephropathy
D) Retinopathy
Correct Answer: B) Peripheral neuropathy
Rationale: Peripheral neuropathy is caused by damage to sensory nerve fibers, which results
in symptoms such as numbness, tingling, pain, and burning, typically in the hands and feet.
,Question 6
A nurse is monitoring a client who is taking risperidone. Which of the following findings should
the nurse identify as a potential adverse effect requiring intervention?
A) Increased heart rate upon standing.
B) A report of dry mouth.
C) A weight gain of 2 pounds in a week.
D) Dizziness when changing from a sitting to a standing position.
Correct Answer: D) Dizziness when changing from a sitting to a standing position.
Rationale: Risperidone, an atypical antipsychotic, can cause orthostatic hypotension. The
nurse should monitor the client's blood pressure for orthostatic changes and instruct the
client to change positions slowly to prevent dizziness and falls.
Question 7
When preparing for a sterile dressing change, which of the following actions demonstrates a
breach in sterile technique?
A) Opening the sterile pack away from the body.
B) Keeping the sterile field above waist level.
C) Pouring sterile solution into a basin on the sterile field.
D) Turning their back to the sterile field to retrieve an item.
Correct Answer: D) Turning their back to the sterile field to retrieve an item.
Rationale: A sterile field is considered contaminated if it is out of the clinician's line of sight.
One must never turn their back on a sterile field.
Question 8
A nurse is teaching a parent about car seat safety for their 18-month-old toddler. Which of the
following statements indicates the parent understands the teaching?
A) "I will place the car seat in a forward-facing position in the back seat."
B) "My toddler should remain in a rear-facing car seat until age 2."
C) "I can place the car seat in the front passenger seat if the airbag is off."
D) "The retainer clip should be placed at the level of the belly button."
Correct Answer: B) "My toddler should remain in a rear-facing car seat until age 2."
, Rationale: Current safety guidelines from the American Academy of Pediatrics recommend
that infants and toddlers remain in a rear-facing car seat until they are at least 2 years of age
or until they reach the highest weight or height allowed by their car seat's manufacturer.
Question 9
A staff nurse is educating a group of newly licensed nurses about organ donation. Which of the
following statements should be included in the teaching?
A) "Any licensed nurse can approach the family to request organ donation."
B) "Organ donation requests should be made by specially trained personnel."
C) "Once a client is declared brain dead, cardiovascular support should be discontinued."
D) "Family discussions about donation should take place in the client's room."
Correct Answer: B) "Organ donation requests should be made by specially trained personnel."
Rationale: The process of requesting organ and tissue donation is a sensitive and complex
conversation that must be handled by personnel who have received specific training (often
from an organ procurement organization) to be effective and supportive.
Question 10
A nurse manager is observing a newly licensed nurse moving a client up in bed. Which of the
following actions by the newly licensed nurse indicates a need for further teaching?
A) Bending at the waist to pull the client up.
B) Raising the bed to a comfortable working height.
C) Asking another staff member for assistance.
D) Using a smooth movement to reposition the client.
Correct Answer: A) Bending at the waist to pull the client up.
Rationale: Bending at the waist (flexion of the spine) places significant strain on the lower
back and increases the risk of injury. Proper body mechanics involve bending at the knees and
hips while keeping the back straight.
Question 11
A child with cystic fibrosis is prescribed therapy with a high-frequency chest compression vest.
The nurse should explain to the parents that the purpose of this device is to:
