RN ATI Capstone Proctored Comprehensive
Assessment 2019 B
Questions 1 - 100
Advanced / Hard / Mixed Difficulty
1. A nurse is caring for a client who is postoperative and has a prescription for
enoxaparin 40 mg subcutaneous daily. Which of the following actions should the
nurse take when administering this medication?
A. Expel the air bubble from the prefilled syringe before injection.
B. Administer the medication in the client's abdomen.
C. Massage the injection site after administration.
D. Aspirate for blood return before injecting.
Exact answer:B
Explanation: Enoxaparin is a low-molecular-weight heparin that is administered
subcutaneously in the abdomen to reduce the risk of deep vein thrombosis. The air
bubble in the prefilled syringe should not be expelled, as it helps ensure the full
dose is delivered. Massaging the site is contraindicated as it can cause bruising.
Aspiration is not recommended for subcutaneous injections of anticoagulants.
2. A nurse is assessing a client who is 2 days postoperative following a hip
arthroplasty. The client reports sudden onset of chest pain and shortness of
breath. The nurse notes tachycardia and tachypnea. Which of the following
actions should the nurse take first?
A. Administer oxygen via nasal cannula at 4 L/min.
B. Notify the healthcare provider immediately.
C. Apply a pulse oximeter to monitor oxygen saturation.
D. Elevate the head of the bed to a semi-Fowler's position.
Exact answer:A
,Explanation: The client's symptoms are consistent with a pulmonary embolism.
The first action is to administer oxygen to maintain oxygenation and prevent
further hypoxia. While notifying the provider and elevating the head of the bed are
important, they follow the initial step of supporting oxygenation. Applying a pulse
oximeter should also be done, but administering oxygen is the priority.
3. A nurse is providing discharge teaching to a client who has a new prescription
for warfarin. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will take an antacid if I experience stomach upset."
B. "I will increase my intake of green leafy vegetables."
C. "I will use a soft-bristled toothbrush."
D. "I will check my blood pressure daily."
Exact answer:C
Explanation: Warfarin is an anticoagulant that increases the risk of bleeding.
Using a soft-bristled toothbrush minimizes the risk of gum bleeding. Antacids can
interact with warfarin. Green leafy vegetables are high in vitamin K and should be
consumed in consistent amounts, not increased. Blood pressure monitoring is not
directly related to warfarin therapy.
4. A nurse is assessing a client who is receiving a blood transfusion. The client
reports chills, lower back pain, and a feeling of impending doom. Which of the
following actions should the nurse take first?
A. Stop the blood transfusion.
B. Notify the healthcare provider.
C. Administer an antihistamine.
D. Obtain a urine specimen.
Exact answer:A
Explanation: The client's symptoms are consistent with an acute hemolytic
transfusion reaction. The priority action is to stop the blood transfusion
immediately to prevent further complications. The nurse should then notify the
,provider, administer antihistamines if prescribed, and obtain a urine specimen, but
stopping the transfusion is the first step.
5. A nurse is caring for a client who has a nasogastric tube attached to
continuous low suction. The nurse notes that the client's abdomen is distended
and bowel sounds are absent. Which of the following actions should the nurse
take?
A. Irrigate the NG tube with 30 mL of normal saline.
B. Position the client on the left side.
C. Notify the healthcare provider.
D. Clamp the NG tube for 15 minutes.
Exact answer:C
Explanation: A distended abdomen and absent bowel sounds in a client with an
NG tube may indicate a bowel obstruction or paralytic ileus. The nurse should
notify the provider immediately. Irrigating the tube or clamping it could worsen
the obstruction or cause reflux and aspiration. Positioning may help with comfort
but does not address the underlying issue.
6. A nurse is providing teaching to a client who has type 1 diabetes mellitus
about sick-day management. Which of the following statements by the client
indicates a need for further teaching?
A. "I will test my urine for ketones every 4 hours."
B. "I will continue to take my insulin even if I am not eating."
C. "I will drink fluids that contain sugar to prevent dehydration."
D. "I will check my blood glucose every 2 to 4 hours."
Exact answer:C
Explanation: During sick days, the client should consume fluids that are sugar-free
or contain electrolytes to prevent dehydration without raising blood glucose
excessively. The client should continue insulin, check blood glucose frequently, and
test for ketones. Drinking sugar-containing fluids can worsen hyperglycemia and
lead to diabetic ketoacidosis.
, 7. A nurse is caring for a client who has heart failure and is receiving furosemide.
Which of the following laboratory values should the nurse monitor to evaluate
the effectiveness of this medication?
A. Serum potassium
B. Serum sodium
C. Serum creatinine
D. Serum calcium
Exact answer:A
Explanation: Furosemide is a loop diuretic that promotes the excretion of
potassium. Monitoring serum potassium levels is important to detect hypokalemia,
a common side effect of the medication. While sodium, creatinine, and calcium
may also be monitored, potassium is the most directly affected and relevant to
evaluating the medication's effect on electrolyte balance.
8. A nurse is assessing a client who has chronic obstructive pulmonary disease
(COPD) and is receiving oxygen at 3 L/min via nasal cannula. The client is
lethargic and has a respiratory rate of 8 breaths/min. Which of the following
actions should the nurse take?
A. Increase the oxygen flow rate to 5 L/min.
B. Administer a bronchodilator.
C. Reduce the oxygen flow rate to 2 L/min.
D. Prepare for intubation.
Exact answer:C
Explanation: Clients with COPD often have a hypoxic drive, meaning their
respiratory drive is stimulated by low oxygen levels. High-flow oxygen can
eliminate this drive, leading to respiratory depression. The nurse should reduce the
oxygen flow rate to 2 L/min and monitor the client. Increasing the flow could
worsen respiratory depression. Intubation is a later intervention.
Assessment 2019 B
Questions 1 - 100
Advanced / Hard / Mixed Difficulty
1. A nurse is caring for a client who is postoperative and has a prescription for
enoxaparin 40 mg subcutaneous daily. Which of the following actions should the
nurse take when administering this medication?
A. Expel the air bubble from the prefilled syringe before injection.
B. Administer the medication in the client's abdomen.
C. Massage the injection site after administration.
D. Aspirate for blood return before injecting.
Exact answer:B
Explanation: Enoxaparin is a low-molecular-weight heparin that is administered
subcutaneously in the abdomen to reduce the risk of deep vein thrombosis. The air
bubble in the prefilled syringe should not be expelled, as it helps ensure the full
dose is delivered. Massaging the site is contraindicated as it can cause bruising.
Aspiration is not recommended for subcutaneous injections of anticoagulants.
2. A nurse is assessing a client who is 2 days postoperative following a hip
arthroplasty. The client reports sudden onset of chest pain and shortness of
breath. The nurse notes tachycardia and tachypnea. Which of the following
actions should the nurse take first?
A. Administer oxygen via nasal cannula at 4 L/min.
B. Notify the healthcare provider immediately.
C. Apply a pulse oximeter to monitor oxygen saturation.
D. Elevate the head of the bed to a semi-Fowler's position.
Exact answer:A
,Explanation: The client's symptoms are consistent with a pulmonary embolism.
The first action is to administer oxygen to maintain oxygenation and prevent
further hypoxia. While notifying the provider and elevating the head of the bed are
important, they follow the initial step of supporting oxygenation. Applying a pulse
oximeter should also be done, but administering oxygen is the priority.
3. A nurse is providing discharge teaching to a client who has a new prescription
for warfarin. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will take an antacid if I experience stomach upset."
B. "I will increase my intake of green leafy vegetables."
C. "I will use a soft-bristled toothbrush."
D. "I will check my blood pressure daily."
Exact answer:C
Explanation: Warfarin is an anticoagulant that increases the risk of bleeding.
Using a soft-bristled toothbrush minimizes the risk of gum bleeding. Antacids can
interact with warfarin. Green leafy vegetables are high in vitamin K and should be
consumed in consistent amounts, not increased. Blood pressure monitoring is not
directly related to warfarin therapy.
4. A nurse is assessing a client who is receiving a blood transfusion. The client
reports chills, lower back pain, and a feeling of impending doom. Which of the
following actions should the nurse take first?
A. Stop the blood transfusion.
B. Notify the healthcare provider.
C. Administer an antihistamine.
D. Obtain a urine specimen.
Exact answer:A
Explanation: The client's symptoms are consistent with an acute hemolytic
transfusion reaction. The priority action is to stop the blood transfusion
immediately to prevent further complications. The nurse should then notify the
,provider, administer antihistamines if prescribed, and obtain a urine specimen, but
stopping the transfusion is the first step.
5. A nurse is caring for a client who has a nasogastric tube attached to
continuous low suction. The nurse notes that the client's abdomen is distended
and bowel sounds are absent. Which of the following actions should the nurse
take?
A. Irrigate the NG tube with 30 mL of normal saline.
B. Position the client on the left side.
C. Notify the healthcare provider.
D. Clamp the NG tube for 15 minutes.
Exact answer:C
Explanation: A distended abdomen and absent bowel sounds in a client with an
NG tube may indicate a bowel obstruction or paralytic ileus. The nurse should
notify the provider immediately. Irrigating the tube or clamping it could worsen
the obstruction or cause reflux and aspiration. Positioning may help with comfort
but does not address the underlying issue.
6. A nurse is providing teaching to a client who has type 1 diabetes mellitus
about sick-day management. Which of the following statements by the client
indicates a need for further teaching?
A. "I will test my urine for ketones every 4 hours."
B. "I will continue to take my insulin even if I am not eating."
C. "I will drink fluids that contain sugar to prevent dehydration."
D. "I will check my blood glucose every 2 to 4 hours."
Exact answer:C
Explanation: During sick days, the client should consume fluids that are sugar-free
or contain electrolytes to prevent dehydration without raising blood glucose
excessively. The client should continue insulin, check blood glucose frequently, and
test for ketones. Drinking sugar-containing fluids can worsen hyperglycemia and
lead to diabetic ketoacidosis.
, 7. A nurse is caring for a client who has heart failure and is receiving furosemide.
Which of the following laboratory values should the nurse monitor to evaluate
the effectiveness of this medication?
A. Serum potassium
B. Serum sodium
C. Serum creatinine
D. Serum calcium
Exact answer:A
Explanation: Furosemide is a loop diuretic that promotes the excretion of
potassium. Monitoring serum potassium levels is important to detect hypokalemia,
a common side effect of the medication. While sodium, creatinine, and calcium
may also be monitored, potassium is the most directly affected and relevant to
evaluating the medication's effect on electrolyte balance.
8. A nurse is assessing a client who has chronic obstructive pulmonary disease
(COPD) and is receiving oxygen at 3 L/min via nasal cannula. The client is
lethargic and has a respiratory rate of 8 breaths/min. Which of the following
actions should the nurse take?
A. Increase the oxygen flow rate to 5 L/min.
B. Administer a bronchodilator.
C. Reduce the oxygen flow rate to 2 L/min.
D. Prepare for intubation.
Exact answer:C
Explanation: Clients with COPD often have a hypoxic drive, meaning their
respiratory drive is stimulated by low oxygen levels. High-flow oxygen can
eliminate this drive, leading to respiratory depression. The nurse should reduce the
oxygen flow rate to 2 L/min and monitor the client. Increasing the flow could
worsen respiratory depression. Intubation is a later intervention.
