ATI CAPSTONE NCLEX PREPARATION AND
REMEDIATION 2026/27 EDITION Q&A
1. A nurse is reviewing a client’s laboratory results. Which of the following findings is
most indicative of acute kidney injury (AKI)?
A. Serum creatinine 0.8 mg/dL
B. BUN 10 mg/dL
C. Serum creatinine 3.2 mg/dL (increase from 0.9 mg/dL over 48 hours)
D. Glomerular filtration rate (GFR) 110 mL/min
Correct Answer: C
*Explanation: A rapid rise in serum creatinine (≥0.3 mg/dL within 48 hours or
≥1.5× baseline) is a key diagnostic criterion for AKI. Options A, B, and D are
within normal ranges.*
2. A client with heart failure is prescribed furosemide 40 mg IV push. Which of the
following assessment findings requires immediate intervention?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium 3.1 mEq/L
C. Urine output 35 mL/hour
D. Blood pressure 120/78 mm Hg
Correct Answer: B
*Explanation: Hypokalemia (K+ <3.5 mEq/L) increases the risk of digoxin toxicity
and cardiac dysrhythmias, especially with loop diuretics. The other options are
expected or acceptable.*
A nurse is providing discharge teaching to a client with a new diagnosis of type 1
diabetes mellitus. Which of the following statements by the client indicates an
understanding of sick-day rules?
A. “I will stop my insulin if I cannot eat.”
B. “I will check my blood glucose every 4 hours.”
, C. “I will drink sugar-free liquids only.”
D. “I will call my doctor only if my blood sugar is above 300 mg/dL.”
Correct Answer: B
Explanation: During illness, blood glucose should be checked every 2–4 hours due
to risk of hyperglycemia from stress hormones. Insulin should never be stopped.
Caloric intake (e.g., broth, juice) should be maintained.
A client is receiving IV heparin for deep vein thrombosis. Which of the following
laboratory values should the nurse monitor to evaluate therapeutic effect?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Correct Answer: C
*Explanation: aPTT is monitored to assess heparin therapy, with therapeutic goal
typically 1.5–2.5 times control. PT/INR monitors warfarin. Platelets monitor for
heparin-induced thrombocytopenia.*
A nurse in a psychiatric unit is caring for a client with bipolar disorder who is
experiencing acute mania. Which of the following interventions should the nurse
implement first?
A. Encourage participation in group therapy
B. Provide high-calorie finger foods
C. Reduce environmental stimuli
D. Restrict fluids to 1500 mL/day
Correct Answer: C
Explanation: Reducing stimuli (low lighting, quiet environment, minimal noise) is
the priority to decrease agitation and risk of injury. Group therapy may exacerbate
mania. Fluids should be encouraged, not restricted.
,A client is postoperative day 1 following a total knee arthroplasty. Which of the
following findings is most concerning for venous thromboembolism?
A. Pain rated 4/10 in the operative knee
B. Swelling and warmth in the calf of the operative leg
C. Ecchymosis around the incision site
D. Heart rate 88 bpm, BP 132/84 mm Hg
Correct Answer: B
Explanation: Unilateral calf swelling, warmth, and pain suggest deep vein
thrombosis. Postoperative pain and ecchymosis are expected. Vital signs are
normal.
A nurse is administering blood products. Which of the following actions is most
important to prevent a transfusion reaction?
A. Verify client identity using two identifiers
B. Infuse blood over 6 hours
C. Premedicate with diphenhydramine
D. Use a microaggregate filter for all blood
Correct Answer: A
*Explanation: Proper patient identification (two identifiers, checking armband and
asking name/DOB) is the most critical step to prevent ABO incompatibility
reactions. Blood should be infused within 4 hours. Filters are not always
required.*
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation
of 88% on room air. The nurse initiates oxygen at 2 L/min via nasal cannula.
Which of the following is a potential complication of oxygen therapy in COPD?
A. Increased carbon dioxide retention
B. Decreased respiratory rate due to hypoxic drive loss
C. Oxygen-induced hyperventilation
D. Absorption atelectasis
Correct Answer: B
Explanation: In some COPD clients with chronic hypercapnia, the respiratory drive
depends on hypoxia. Excess oxygen can reduce this drive, causing hypoventilation
, and worsened hypercapnia. Newer evidence suggests this is less common but still
monitored.
A nurse is assessing a client who is receiving a continuous tube feeding. Which of the
following findings should the nurse report to the provider immediately?
A. Gastric residual volume of 200 mL
B. Blood glucose 150 mg/dL
C. Respiratory rate 26/min with crackles in lung bases
D. Diarrhea for the past 24 hours
Correct Answer: C
*Explanation: Tachypnea and crackles suggest aspiration pneumonia, a life-
threatening complication of tube feeding. This requires immediate intervention.
GRV up to 500 mL may be acceptable. Mild hyperglycemia and diarrhea are less
urgent.*
A nurse is teaching a client about warfarin therapy. Which of the following
statements by the client indicates a need for further teaching?
A. “I will eat more green leafy vegetables for fiber.”
B. “I will use an electric razor to shave.”
C. “I will notify my dentist that I take warfarin.”
D. “I will have my INR checked regularly.”
Correct Answer: A
Explanation: Green leafy vegetables are high in vitamin K, which antagonizes
warfarin. Consistent intake is okay, but increasing intake can lower INR. Electric
razors and dental notification are correct safety measures.
A nurse is caring for a client with increased intracranial pressure (ICP) following a
traumatic brain injury. Which of the following nursing actions is contraindicated?
A. Elevating the head of the bed to 30 degrees
B. Suctioning the airway every 2 hours
C. Maintaining normothermia
REMEDIATION 2026/27 EDITION Q&A
1. A nurse is reviewing a client’s laboratory results. Which of the following findings is
most indicative of acute kidney injury (AKI)?
A. Serum creatinine 0.8 mg/dL
B. BUN 10 mg/dL
C. Serum creatinine 3.2 mg/dL (increase from 0.9 mg/dL over 48 hours)
D. Glomerular filtration rate (GFR) 110 mL/min
Correct Answer: C
*Explanation: A rapid rise in serum creatinine (≥0.3 mg/dL within 48 hours or
≥1.5× baseline) is a key diagnostic criterion for AKI. Options A, B, and D are
within normal ranges.*
2. A client with heart failure is prescribed furosemide 40 mg IV push. Which of the
following assessment findings requires immediate intervention?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium 3.1 mEq/L
C. Urine output 35 mL/hour
D. Blood pressure 120/78 mm Hg
Correct Answer: B
*Explanation: Hypokalemia (K+ <3.5 mEq/L) increases the risk of digoxin toxicity
and cardiac dysrhythmias, especially with loop diuretics. The other options are
expected or acceptable.*
A nurse is providing discharge teaching to a client with a new diagnosis of type 1
diabetes mellitus. Which of the following statements by the client indicates an
understanding of sick-day rules?
A. “I will stop my insulin if I cannot eat.”
B. “I will check my blood glucose every 4 hours.”
, C. “I will drink sugar-free liquids only.”
D. “I will call my doctor only if my blood sugar is above 300 mg/dL.”
Correct Answer: B
Explanation: During illness, blood glucose should be checked every 2–4 hours due
to risk of hyperglycemia from stress hormones. Insulin should never be stopped.
Caloric intake (e.g., broth, juice) should be maintained.
A client is receiving IV heparin for deep vein thrombosis. Which of the following
laboratory values should the nurse monitor to evaluate therapeutic effect?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Correct Answer: C
*Explanation: aPTT is monitored to assess heparin therapy, with therapeutic goal
typically 1.5–2.5 times control. PT/INR monitors warfarin. Platelets monitor for
heparin-induced thrombocytopenia.*
A nurse in a psychiatric unit is caring for a client with bipolar disorder who is
experiencing acute mania. Which of the following interventions should the nurse
implement first?
A. Encourage participation in group therapy
B. Provide high-calorie finger foods
C. Reduce environmental stimuli
D. Restrict fluids to 1500 mL/day
Correct Answer: C
Explanation: Reducing stimuli (low lighting, quiet environment, minimal noise) is
the priority to decrease agitation and risk of injury. Group therapy may exacerbate
mania. Fluids should be encouraged, not restricted.
,A client is postoperative day 1 following a total knee arthroplasty. Which of the
following findings is most concerning for venous thromboembolism?
A. Pain rated 4/10 in the operative knee
B. Swelling and warmth in the calf of the operative leg
C. Ecchymosis around the incision site
D. Heart rate 88 bpm, BP 132/84 mm Hg
Correct Answer: B
Explanation: Unilateral calf swelling, warmth, and pain suggest deep vein
thrombosis. Postoperative pain and ecchymosis are expected. Vital signs are
normal.
A nurse is administering blood products. Which of the following actions is most
important to prevent a transfusion reaction?
A. Verify client identity using two identifiers
B. Infuse blood over 6 hours
C. Premedicate with diphenhydramine
D. Use a microaggregate filter for all blood
Correct Answer: A
*Explanation: Proper patient identification (two identifiers, checking armband and
asking name/DOB) is the most critical step to prevent ABO incompatibility
reactions. Blood should be infused within 4 hours. Filters are not always
required.*
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation
of 88% on room air. The nurse initiates oxygen at 2 L/min via nasal cannula.
Which of the following is a potential complication of oxygen therapy in COPD?
A. Increased carbon dioxide retention
B. Decreased respiratory rate due to hypoxic drive loss
C. Oxygen-induced hyperventilation
D. Absorption atelectasis
Correct Answer: B
Explanation: In some COPD clients with chronic hypercapnia, the respiratory drive
depends on hypoxia. Excess oxygen can reduce this drive, causing hypoventilation
, and worsened hypercapnia. Newer evidence suggests this is less common but still
monitored.
A nurse is assessing a client who is receiving a continuous tube feeding. Which of the
following findings should the nurse report to the provider immediately?
A. Gastric residual volume of 200 mL
B. Blood glucose 150 mg/dL
C. Respiratory rate 26/min with crackles in lung bases
D. Diarrhea for the past 24 hours
Correct Answer: C
*Explanation: Tachypnea and crackles suggest aspiration pneumonia, a life-
threatening complication of tube feeding. This requires immediate intervention.
GRV up to 500 mL may be acceptable. Mild hyperglycemia and diarrhea are less
urgent.*
A nurse is teaching a client about warfarin therapy. Which of the following
statements by the client indicates a need for further teaching?
A. “I will eat more green leafy vegetables for fiber.”
B. “I will use an electric razor to shave.”
C. “I will notify my dentist that I take warfarin.”
D. “I will have my INR checked regularly.”
Correct Answer: A
Explanation: Green leafy vegetables are high in vitamin K, which antagonizes
warfarin. Consistent intake is okay, but increasing intake can lower INR. Electric
razors and dental notification are correct safety measures.
A nurse is caring for a client with increased intracranial pressure (ICP) following a
traumatic brain injury. Which of the following nursing actions is contraindicated?
A. Elevating the head of the bed to 30 degrees
B. Suctioning the airway every 2 hours
C. Maintaining normothermia
