ATI RN Capstone Proctored Post
Assessment Exam with correct
questions and answers with
rationale new!!
FUNDAMENTALS & ASSESSMENT (Questions 1–15)
1. A nurse is caring for a client who received 0.9% sodium chloride 1,000 mL IV over 4 hours instead
of the prescribed 8 hours. Which assessment finding requires immediate intervention?
A. Urine output 35 mL/hr
B. Crackles in bilateral lung bases
C. Weight gain of 0.5 kg from admission
D. Bounding peripheral pulses
Answer: B
Rationale: Fluid volume overload is the priority concern with rapid infusion of isotonic crystalloids.
Crackles indicate pulmonary edema, which can progress to respiratory failure. While bounding
pulses (D) and weight gain (C) indicate fluid excess, crackles represent actual compromise of gas
exchange. Urine output of 35 mL/hr (A) is within normal range (0.5-1 mL/kg/hr).
2. When assessing a client with acute pancreatitis, which finding indicates a potential complication
requiring immediate notification of the provider?
A. Pain rated 8/10 unrelieved by morphine
B. Cullen's sign (periumbilical ecchymosis)
C. Decreased bowel sounds in all quadrants
D. Blood glucose level of 180 mg/dL
Answer: B
Rationale: Cullen's sign indicates retroperitoneal hemorrhage, a life-threatening complication of
hemorrhagic pancreatitis. While severe pain (A) requires attention, it is expected in pancreatitis.
,Hypoactive bowel sounds (C) are common due to paralytic ileus, and hyperglycemia (D) results from
beta-cell dysfunction but is not immediately life-threatening at this level.
3. A client is receiving heparin therapy. The nurse notes the aPTT is 90 seconds (therapeutic range:
60–80 seconds). Which action is most appropriate?
A. Stop the heparin infusion immediately
B. Reduce the infusion rate per protocol
C. Administer protamine sulfate
D. Continue current rate and reassess in 4 hours
Answer: B
Rationale: A mildly elevated aPTT (90 seconds) indicates supratherapeutic anticoagulation but not
critical bleeding risk. The nurse should decrease the rate per institutional protocol. Stopping the
infusion (A) or giving protamine (C) is reserved for severe bleeding or critical overdose. Continuing
the current rate (D) increases bleeding risk.
4. Which intervention demonstrates correct understanding of transmission-based precautions for a
client with Clostridioides difficile infection?
A. Placing the client in a negative-pressure room
B. Performing hand hygiene with alcohol-based sanitizer
C. Wearing a gown and gloves when entering the room
D. Placing the client on droplet precautions
Answer: C
Rationale: C. difficile requires Contact Precautions (gown and gloves) due to spore transmission via
direct contact. Alcohol-based sanitizers (B) do not kill spores; soap and water is required. Negative-
pressure rooms (A) are for Airborne Precautions. Droplet precautions (D) are inappropriate as C.
difficile is not transmitted via respiratory droplets.
5. A nurse is delegating tasks to assistive personnel (AP). Which task is appropriate to delegate?
A. Assessing pain in a client 2 hours post-op
B. Performing blood glucose monitoring on a stable diabetic client
C. Teaching a client about insulin administration
,D. Evaluating the effectiveness of antihypertensive medication
Answer: B
Rationale: Blood glucose monitoring is a standardized, routine procedure appropriate for AP
delegation. Assessment (A), teaching (C), and evaluation of medication effectiveness (D) require
nursing judgment and cannot be delegated to unlicensed personnel.
6. A client reports severe pain following thoracic surgery. The nurse administers morphine 4 mg IV as
prescribed. Which finding indicates the priority assessment 30 minutes later?
A. Respiratory rate of 10 breaths/min
B. Pain rating decreased to 3/10
C. Sedation scale of 2 (dozing but awakens easily)
D. Blood pressure 110/70 mmHg
Answer: A
Rationale: Opioid-induced respiratory depression is the most serious adverse effect. A respiratory
rate below 12 breaths/min requires immediate intervention (stimulating client, possible naloxone
administration). While pain relief (B) is desired, airway and breathing take priority per ABCs.
7. A nurse is caring for a client with a chest tube connected to suction. Which observation requires
immediate intervention?
A. Fluctuation in the water-seal chamber with inspiration
B. 50 mL of serosanguineous drainage in 4 hours
C. Bubbling in the suction control chamber
D. Disconnection of the tubing from the drainage system
Answer: D
Rationale: An open chest drainage system creates a direct pathway for air into the pleural space,
risking tension pneumothorax. The nurse should immediately clamp the tube closest to the client
(momentarily) while preparing to reconnect or submerge the end in sterile water. Fluctuation (A) is
expected with inspiration, moderate drainage (B) is normal post-op, and bubbling (C) indicates
suction is functioning.
8. Which laboratory value indicates the client is experiencing syndrome of inappropriate antidiuretic
hormone (SIADH)?
, A. Serum sodium 118 mEq/L
B. Serum osmolality 310 mOsm/kg
C. Urine specific gravity 1.005
D. Hematocrit 48%
Answer: A
Rationale: SIADH causes dilutional hyponatremia (serum sodium <135 mEq/L, often <130). Serum
osmolality decreases (<275 mOsm/kg) in SIADH, not increases. Urine specific gravity is high (>1.030)
due to water retention. Hematocrit decreases due to hemodilution.
9. A nurse is preparing to administer warfarin 5 mg PO. Which finding requires holding the dose and
contacting the provider?
A. INR 3.5
B. aPTT 45 seconds
C. Platelet count 150,000/mm³
D. Blood pressure 140/90 mmHg
Answer: A
Rationale: Therapeutic INR for warfarin therapy is typically 2.0–3.0 (or 2.5–3.5 for mechanical
valves). An INR of 3.5 indicates supratherapeutic anticoagulation with bleeding risk. aPTT (B)
monitors heparin, not warfarin. Platelet count (C) is within normal limits (150,000–400,000).
10. A client with heart failure is prescribed furosemide 40 mg IV push. Which assessment finding
indicates the medication is achieving the desired effect?
A. Decreased dyspnea with activity
B. Dry mucous membranes
C. Decreased potassium level
D. Increased hematocrit
Answer: A
Rationale: Furosemide reduces preload and afterload, improving cardiac output and relieving
pulmonary congestion, thereby decreasing dyspnea. While hypokalemia (C) and hemoconcentration
(D) are effects of diuresis, they are adverse effects, not therapeutic goals. Dry mucous membranes
(B) indicate excessive fluid loss.
Assessment Exam with correct
questions and answers with
rationale new!!
FUNDAMENTALS & ASSESSMENT (Questions 1–15)
1. A nurse is caring for a client who received 0.9% sodium chloride 1,000 mL IV over 4 hours instead
of the prescribed 8 hours. Which assessment finding requires immediate intervention?
A. Urine output 35 mL/hr
B. Crackles in bilateral lung bases
C. Weight gain of 0.5 kg from admission
D. Bounding peripheral pulses
Answer: B
Rationale: Fluid volume overload is the priority concern with rapid infusion of isotonic crystalloids.
Crackles indicate pulmonary edema, which can progress to respiratory failure. While bounding
pulses (D) and weight gain (C) indicate fluid excess, crackles represent actual compromise of gas
exchange. Urine output of 35 mL/hr (A) is within normal range (0.5-1 mL/kg/hr).
2. When assessing a client with acute pancreatitis, which finding indicates a potential complication
requiring immediate notification of the provider?
A. Pain rated 8/10 unrelieved by morphine
B. Cullen's sign (periumbilical ecchymosis)
C. Decreased bowel sounds in all quadrants
D. Blood glucose level of 180 mg/dL
Answer: B
Rationale: Cullen's sign indicates retroperitoneal hemorrhage, a life-threatening complication of
hemorrhagic pancreatitis. While severe pain (A) requires attention, it is expected in pancreatitis.
,Hypoactive bowel sounds (C) are common due to paralytic ileus, and hyperglycemia (D) results from
beta-cell dysfunction but is not immediately life-threatening at this level.
3. A client is receiving heparin therapy. The nurse notes the aPTT is 90 seconds (therapeutic range:
60–80 seconds). Which action is most appropriate?
A. Stop the heparin infusion immediately
B. Reduce the infusion rate per protocol
C. Administer protamine sulfate
D. Continue current rate and reassess in 4 hours
Answer: B
Rationale: A mildly elevated aPTT (90 seconds) indicates supratherapeutic anticoagulation but not
critical bleeding risk. The nurse should decrease the rate per institutional protocol. Stopping the
infusion (A) or giving protamine (C) is reserved for severe bleeding or critical overdose. Continuing
the current rate (D) increases bleeding risk.
4. Which intervention demonstrates correct understanding of transmission-based precautions for a
client with Clostridioides difficile infection?
A. Placing the client in a negative-pressure room
B. Performing hand hygiene with alcohol-based sanitizer
C. Wearing a gown and gloves when entering the room
D. Placing the client on droplet precautions
Answer: C
Rationale: C. difficile requires Contact Precautions (gown and gloves) due to spore transmission via
direct contact. Alcohol-based sanitizers (B) do not kill spores; soap and water is required. Negative-
pressure rooms (A) are for Airborne Precautions. Droplet precautions (D) are inappropriate as C.
difficile is not transmitted via respiratory droplets.
5. A nurse is delegating tasks to assistive personnel (AP). Which task is appropriate to delegate?
A. Assessing pain in a client 2 hours post-op
B. Performing blood glucose monitoring on a stable diabetic client
C. Teaching a client about insulin administration
,D. Evaluating the effectiveness of antihypertensive medication
Answer: B
Rationale: Blood glucose monitoring is a standardized, routine procedure appropriate for AP
delegation. Assessment (A), teaching (C), and evaluation of medication effectiveness (D) require
nursing judgment and cannot be delegated to unlicensed personnel.
6. A client reports severe pain following thoracic surgery. The nurse administers morphine 4 mg IV as
prescribed. Which finding indicates the priority assessment 30 minutes later?
A. Respiratory rate of 10 breaths/min
B. Pain rating decreased to 3/10
C. Sedation scale of 2 (dozing but awakens easily)
D. Blood pressure 110/70 mmHg
Answer: A
Rationale: Opioid-induced respiratory depression is the most serious adverse effect. A respiratory
rate below 12 breaths/min requires immediate intervention (stimulating client, possible naloxone
administration). While pain relief (B) is desired, airway and breathing take priority per ABCs.
7. A nurse is caring for a client with a chest tube connected to suction. Which observation requires
immediate intervention?
A. Fluctuation in the water-seal chamber with inspiration
B. 50 mL of serosanguineous drainage in 4 hours
C. Bubbling in the suction control chamber
D. Disconnection of the tubing from the drainage system
Answer: D
Rationale: An open chest drainage system creates a direct pathway for air into the pleural space,
risking tension pneumothorax. The nurse should immediately clamp the tube closest to the client
(momentarily) while preparing to reconnect or submerge the end in sterile water. Fluctuation (A) is
expected with inspiration, moderate drainage (B) is normal post-op, and bubbling (C) indicates
suction is functioning.
8. Which laboratory value indicates the client is experiencing syndrome of inappropriate antidiuretic
hormone (SIADH)?
, A. Serum sodium 118 mEq/L
B. Serum osmolality 310 mOsm/kg
C. Urine specific gravity 1.005
D. Hematocrit 48%
Answer: A
Rationale: SIADH causes dilutional hyponatremia (serum sodium <135 mEq/L, often <130). Serum
osmolality decreases (<275 mOsm/kg) in SIADH, not increases. Urine specific gravity is high (>1.030)
due to water retention. Hematocrit decreases due to hemodilution.
9. A nurse is preparing to administer warfarin 5 mg PO. Which finding requires holding the dose and
contacting the provider?
A. INR 3.5
B. aPTT 45 seconds
C. Platelet count 150,000/mm³
D. Blood pressure 140/90 mmHg
Answer: A
Rationale: Therapeutic INR for warfarin therapy is typically 2.0–3.0 (or 2.5–3.5 for mechanical
valves). An INR of 3.5 indicates supratherapeutic anticoagulation with bleeding risk. aPTT (B)
monitors heparin, not warfarin. Platelet count (C) is within normal limits (150,000–400,000).
10. A client with heart failure is prescribed furosemide 40 mg IV push. Which assessment finding
indicates the medication is achieving the desired effect?
A. Decreased dyspnea with activity
B. Dry mucous membranes
C. Decreased potassium level
D. Increased hematocrit
Answer: A
Rationale: Furosemide reduces preload and afterload, improving cardiac output and relieving
pulmonary congestion, thereby decreasing dyspnea. While hypokalemia (C) and hemoconcentration
(D) are effects of diuresis, they are adverse effects, not therapeutic goals. Dry mucous membranes
(B) indicate excessive fluid loss.
