ATI PN CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT test
bank
720-Question Practice Examination with Multiple Answers, Correct
Answers Highlighted, and Detailed Rationales
SECTION 1: FUNDAMENTALS OF NURSING & PATIENT SAFETY (Questions 1–25)
Question 1: A nurse is planning to collect a stool specimen for ova and parasites from a client
who has diarrhea. Which of the following actions should the nurse take?
• A. Collect the specimen from the toilet bowl
• B. Refrigerate the specimen immediately after collection
• C. Instruct the client to defecate into a clean, dry container
• D. Collect three separate specimens over 5 days
Rationale: Specimens for ova and parasite testing should be collected in a clean, dry container
and delivered to the lab while still warm. Refrigeration is not indicated, and toilet water can
contaminate the specimen.
Question 2: A nurse is caring for a client who has dementia. Which of the following actions
should the nurse take to promote communication?
• A. Speak in a loud voice
• B. Face the client at eye level when communicating
• C. Use complex sentences
• D. Approach the client from behind
Rationale: Facing the client at eye level reduces intimidation and helps the client focus on
nonverbal cues. Loud voice and complex sentences can increase confusion in clients with
dementia.
Question 3: A nurse is preparing to administer a blood transfusion. Which of the following
actions should the nurse take first?
• A. Obtain the client's vital signs
• B. Verify the client's identity using two identifiers
• C. Prime the blood tubing with normal saline
, • D. Check the expiration date on the blood product
Rationale: Verification of client identity using two identifiers is the priority action to ensure the
correct blood product is administered to the correct client, preventing transfusion errors.
Question 4: A client receiving a blood transfusion reports chills and low back pain. The PN notes
a fever of 101.5°F. What is the priority action?
• A. Stop the transfusion
• B. Slow the infusion rate
• C. Notify the charge nurse
• D. Obtain a urine specimen
Rationale: Chills, fever, and back pain suggest an acute hemolytic transfusion reaction. The
priority action is to stop the transfusion immediately to prevent further complications.
Question 5: A nurse is caring for a client who has a chest tube following a thoracotomy. Which
of the following findings requires immediate intervention?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. 100 mL of drainage in the first 8 hours
• D. Pain at the insertion site
Rationale: Continuous bubbling in the water seal chamber indicates an air leak that requires
immediate intervention. Tidaling is a normal finding, and 100 mL drainage in 8 hours is within
acceptable parameters. Pain at the insertion site is expected.
Question 6: A nurse is reinforcing discharge teaching with a client who has a new colostomy.
Which of the following statements by the client indicates understanding?
• A. "I will change the ostomy pouch every day."
• B. "I will avoid eating foods that cause gas and odor."
• C. "I can resume heavy lifting immediately."
• D. "I do not need to worry about skin care around the stoma."
Rationale: Clients with a new colostomy should avoid gas-forming and odor-producing foods.
The pouch should be changed when needed, not necessarily daily. Heavy lifting should be
avoided initially, and proper skin care around the stoma is essential.
,Question 7: A nurse is assessing a client who has a pressure ulcer. Which of the following
findings is a manifestation of a Stage 3 pressure ulcer?
• A. Non-blanchable erythema of intact skin
• B. Partial-thickness skin loss with exposed dermis
• C. Full-thickness skin loss with visible subcutaneous tissue
• D. Full-thickness tissue loss with exposed bone
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous
tissue. Stage 1 involves non-blanchable erythema; Stage 2 involves partial-thickness loss; Stage
4 involves exposed bone, tendon, or muscle.
Question 8: A nurse is preparing to insert a nasogastric (NG) tube. Which of the following
actions should the nurse take to verify proper placement?
• A. Inject air and listen for gurgling over the stomach
• B. Obtain an abdominal X-ray
• C. Aspirate gastric contents and check pH
• D. Measure the external length of the tube
Rationale: An abdominal X-ray is the gold standard for confirming NG tube placement. While
auscultation and pH testing are used, X-ray provides definitive confirmation.
Question 9: A nurse is providing teaching to a client who is prescribed warfarin. Which of the
following client statements indicates understanding?
• A. "I will take ibuprofen for headaches."
• B. "I will eat more leafy green vegetables."
• C. "I will notify my dentist that I take this medication."
• D. "I will stop taking this medication if I see bruising."
Rationale: Clients taking warfarin should inform all healthcare providers, including dentists, to
prevent excessive bleeding during procedures. Leafy green vegetables contain vitamin K and
should be consumed consistently, not increased suddenly. Bruising is an expected side effect.
Question 10: A nurse is preparing to administer a medication via a nasogastric tube. Which of
the following actions should the nurse take?
• A. Crush enteric-coated tablets before administration
• B. Flush the tube with 30 mL of water before and after each medication
, • C. Mix all medications together in one syringe
• D. Administer medications at the same time as enteral feedings
Rationale: The tube should be flushed with 30 mL of water before and after each medication to
maintain patency and prevent clogging. Enteric-coated tablets should not be crushed.
Medications should not be mixed together unless compatibility is confirmed.
Question 11: A nurse is assessing a client's pain level. The client has dementia and difficulty
communicating. Which pain assessment technique should the nurse use?
• A. PAINAD scale
• B. Numeric rating scale
• C. Visual analog scale
• D. Wong-Baker FACES scale
Rationale: The PAINAD (Pain Assessment in Advanced Dementia) scale is specifically designed
for clients with dementia who cannot self-report pain. Numeric, visual analog, and FACES scales
require cognitive ability to self-report.
Question 12: A nurse is providing oral care to an unconscious client. Which of the following
actions should the nurse take?
• A. Place the client in a supine position
• B. Position the client on the side with the head turned to the side
• C. Use a toothbrush with stiff bristles
• D. Apply lemon-glycerin swabs for oral hygiene
Rationale: Positioning the client on the side with the head turned prevents aspiration of fluids.
Supine position increases aspiration risk. Soft bristles should be used, and lemon-glycerin swabs
can dry oral mucosa.
Question 13: A nurse is preparing to apply a restraint to a client. Which of the following actions
is appropriate?
• A. Apply the restraint tightly to prevent movement
• B. Obtain a provider's order before application
• C. Tie the restraint to the side rail of the bed
• D. Leave the restraint on for 4 hours before reassessment
bank
720-Question Practice Examination with Multiple Answers, Correct
Answers Highlighted, and Detailed Rationales
SECTION 1: FUNDAMENTALS OF NURSING & PATIENT SAFETY (Questions 1–25)
Question 1: A nurse is planning to collect a stool specimen for ova and parasites from a client
who has diarrhea. Which of the following actions should the nurse take?
• A. Collect the specimen from the toilet bowl
• B. Refrigerate the specimen immediately after collection
• C. Instruct the client to defecate into a clean, dry container
• D. Collect three separate specimens over 5 days
Rationale: Specimens for ova and parasite testing should be collected in a clean, dry container
and delivered to the lab while still warm. Refrigeration is not indicated, and toilet water can
contaminate the specimen.
Question 2: A nurse is caring for a client who has dementia. Which of the following actions
should the nurse take to promote communication?
• A. Speak in a loud voice
• B. Face the client at eye level when communicating
• C. Use complex sentences
• D. Approach the client from behind
Rationale: Facing the client at eye level reduces intimidation and helps the client focus on
nonverbal cues. Loud voice and complex sentences can increase confusion in clients with
dementia.
Question 3: A nurse is preparing to administer a blood transfusion. Which of the following
actions should the nurse take first?
• A. Obtain the client's vital signs
• B. Verify the client's identity using two identifiers
• C. Prime the blood tubing with normal saline
, • D. Check the expiration date on the blood product
Rationale: Verification of client identity using two identifiers is the priority action to ensure the
correct blood product is administered to the correct client, preventing transfusion errors.
Question 4: A client receiving a blood transfusion reports chills and low back pain. The PN notes
a fever of 101.5°F. What is the priority action?
• A. Stop the transfusion
• B. Slow the infusion rate
• C. Notify the charge nurse
• D. Obtain a urine specimen
Rationale: Chills, fever, and back pain suggest an acute hemolytic transfusion reaction. The
priority action is to stop the transfusion immediately to prevent further complications.
Question 5: A nurse is caring for a client who has a chest tube following a thoracotomy. Which
of the following findings requires immediate intervention?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. 100 mL of drainage in the first 8 hours
• D. Pain at the insertion site
Rationale: Continuous bubbling in the water seal chamber indicates an air leak that requires
immediate intervention. Tidaling is a normal finding, and 100 mL drainage in 8 hours is within
acceptable parameters. Pain at the insertion site is expected.
Question 6: A nurse is reinforcing discharge teaching with a client who has a new colostomy.
Which of the following statements by the client indicates understanding?
• A. "I will change the ostomy pouch every day."
• B. "I will avoid eating foods that cause gas and odor."
• C. "I can resume heavy lifting immediately."
• D. "I do not need to worry about skin care around the stoma."
Rationale: Clients with a new colostomy should avoid gas-forming and odor-producing foods.
The pouch should be changed when needed, not necessarily daily. Heavy lifting should be
avoided initially, and proper skin care around the stoma is essential.
,Question 7: A nurse is assessing a client who has a pressure ulcer. Which of the following
findings is a manifestation of a Stage 3 pressure ulcer?
• A. Non-blanchable erythema of intact skin
• B. Partial-thickness skin loss with exposed dermis
• C. Full-thickness skin loss with visible subcutaneous tissue
• D. Full-thickness tissue loss with exposed bone
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous
tissue. Stage 1 involves non-blanchable erythema; Stage 2 involves partial-thickness loss; Stage
4 involves exposed bone, tendon, or muscle.
Question 8: A nurse is preparing to insert a nasogastric (NG) tube. Which of the following
actions should the nurse take to verify proper placement?
• A. Inject air and listen for gurgling over the stomach
• B. Obtain an abdominal X-ray
• C. Aspirate gastric contents and check pH
• D. Measure the external length of the tube
Rationale: An abdominal X-ray is the gold standard for confirming NG tube placement. While
auscultation and pH testing are used, X-ray provides definitive confirmation.
Question 9: A nurse is providing teaching to a client who is prescribed warfarin. Which of the
following client statements indicates understanding?
• A. "I will take ibuprofen for headaches."
• B. "I will eat more leafy green vegetables."
• C. "I will notify my dentist that I take this medication."
• D. "I will stop taking this medication if I see bruising."
Rationale: Clients taking warfarin should inform all healthcare providers, including dentists, to
prevent excessive bleeding during procedures. Leafy green vegetables contain vitamin K and
should be consumed consistently, not increased suddenly. Bruising is an expected side effect.
Question 10: A nurse is preparing to administer a medication via a nasogastric tube. Which of
the following actions should the nurse take?
• A. Crush enteric-coated tablets before administration
• B. Flush the tube with 30 mL of water before and after each medication
, • C. Mix all medications together in one syringe
• D. Administer medications at the same time as enteral feedings
Rationale: The tube should be flushed with 30 mL of water before and after each medication to
maintain patency and prevent clogging. Enteric-coated tablets should not be crushed.
Medications should not be mixed together unless compatibility is confirmed.
Question 11: A nurse is assessing a client's pain level. The client has dementia and difficulty
communicating. Which pain assessment technique should the nurse use?
• A. PAINAD scale
• B. Numeric rating scale
• C. Visual analog scale
• D. Wong-Baker FACES scale
Rationale: The PAINAD (Pain Assessment in Advanced Dementia) scale is specifically designed
for clients with dementia who cannot self-report pain. Numeric, visual analog, and FACES scales
require cognitive ability to self-report.
Question 12: A nurse is providing oral care to an unconscious client. Which of the following
actions should the nurse take?
• A. Place the client in a supine position
• B. Position the client on the side with the head turned to the side
• C. Use a toothbrush with stiff bristles
• D. Apply lemon-glycerin swabs for oral hygiene
Rationale: Positioning the client on the side with the head turned prevents aspiration of fluids.
Supine position increases aspiration risk. Soft bristles should be used, and lemon-glycerin swabs
can dry oral mucosa.
Question 13: A nurse is preparing to apply a restraint to a client. Which of the following actions
is appropriate?
• A. Apply the restraint tightly to prevent movement
• B. Obtain a provider's order before application
• C. Tie the restraint to the side rail of the bed
• D. Leave the restraint on for 4 hours before reassessment
