ATI CAPSTONE PROCTORED FUNDAMENTALS VERSION 2/NEWEST UPDATE 2026
Question 1
A nurse is developing a plan of care for a client who has dysphagia. Which of the following
interventions should the nurse include?
A) Provide the client with a straw for all liquids.
B) Encourage the client to tilt their head back when swallowing.
C) Have the client sit upright for 1 hr following meals.
D) Give the client thin liquids to make swallowing easier.
E) Offer the client large bites of food to stimulate the gag reflex.
Correct Answer: C) Have the client sit upright for 1 hr following meals.
Rationale: Clients with dysphagia are at high risk for aspiration pneumonia. Maintaining
an upright position (High-Fowler's or sitting in a chair) during and for at least 30 to 60
minutes after meals uses gravity to assist the passage of food into the stomach and prevents
gastric reflux and aspiration. Straws should be avoided as they can increase the risk of
aspiration by delivering too much fluid too quickly. Thin liquids are more difficult to
control for a client with dysphagia; thickened liquids are usually preferred.
Question 2
A nurse is assessing an infusion IV site and notes the client reports pain. The site is red and warm
to the touch. Which of the following actions should the nurse take?
A) Slow the infusion rate until the pain subsides.
B) Apply a cold compress to the site for 30 minutes.
C) Discontinue the infusion and remove the IV catheter.
D) Flush the catheter with 10 mL of normal saline.
E) Elevate the extremity and continue the infusion.
Correct Answer: C) Discontinue the infusion and remove the IV catheter.
Rationale: Pain, redness, and warmth at an IV site are classic manifestations of phlebitis
(inflammation of the vein). The priority action when a complication such as phlebitis,
infiltration, or extravasation is identified is to stop the infusion and remove the catheter to
prevent further tissue or vein damage. After removal, the nurse should apply a warm
compress and document the finding using a phlebitis scale.
Question 3
A nurse is performing a routine abdominal assessment for a client. Which of the following
sequences should the nurse follow?
A) Palpation, percussion, auscultation, inspection.
B) Inspection, auscultation, percussion, palpation.
C) Auscultation, inspection, palpation, percussion.
D) Inspection, palpation, percussion, auscultation.
E) Percussion, auscultation, inspection, palpation.
, 2
Correct Answer: B) Inspection, auscultation, percussion, palpation.
Rationale: The standard order of physical assessment is inspection, palpation, percussion,
and auscultation. However, for the abdomen, the sequence is modified. The nurse must
perform palpation and percussion AFTER auscultation because touching or pressing on the
abdomen can stimulate peristalsis, which would result in false or altered bowel sounds
during auscultation.
Question 4
A nurse is teaching a group of new nurses about the different types of immunity. Which of the
following information should the nurse include?
A) Passive immunity is permanent and lasts a lifetime.
B) The body produces antibodies in response to an antigen with active immunity.
C) Active immunity is acquired through the transfer of antibodies from a mother to a fetus.
D) Passive immunity occurs when a person is exposed to a live pathogen.
E) Active immunity provides immediate protection against a pathogen.
Correct Answer: B) The body produces antibodies in response to an antigen with active
immunity.
Rationale: Active immunity occurs when the body's own immune system produces
antibodies in response to exposure to a foreign antigen, either through contracting a disease
(natural active) or receiving a vaccine (artificial active). Passive immunity involves
receiving antibodies from an outside source (like maternal-fetal transfer or
immunoglobulin injections), provides immediate but temporary protection, and does not
result in the formation of memory cells.
Question 5
A nurse is assessing an older adult client for risk factors for infection. Which of the following
findings should the nurse identify as an age-related change that increases this risk?
A) Increased production of digestive enzymes.
B) Heightened inflammatory response.
C) Lowered immune system function.
D) Increased elasticity of the skin.
E) Enhanced cough reflex.
Correct Answer: C) Lowered immune system function.
Rationale: The aging process leads to "immunosenescence," which is a gradual decrease in
immune system function. Older adults have a decreased production of T-cells and B-cells,
making them more susceptible to infections and reducing their response to vaccinations.
Other factors include thinned skin (loss of protective barrier) and a decreased cough reflex,
which makes it harder to clear secretions from the lungs.
, 3
Question 6
A nurse is teaching a client about the correct use of a Metered-Dose Inhaler (MDI). Which of the
following instructions should the nurse include?
A) Exhale quickly after inhaling the medication.
B) Inhale medication deeply for 3 to 5 seconds.
C) Wait 10 seconds between puffs of the same medication.
D) Shake the inhaler for 2 seconds before use.
E) Hold the breath for 2 seconds after inhalation.
Correct Answer: B) Inhale medication deeply for 3 to 5 seconds.
Rationale: When using an MDI, the client should breathe in slowly and deeply for 3 to 5
seconds while depressing the canister to ensure the medication reaches the lower airways.
After inhalation, the client should hold their breath for about 10 seconds to allow the
medication to settle in the lungs. If a second puff is required, the client should wait 1 to 2
minutes between puffs.
Question 7
A nurse is performing a focused assessment on a client who has a history of COPD and is
experiencing dyspnea. Which of the following findings should the nurse expect?
A) Bradypnea.
B) Flaring of the nostrils.
C) A respiratory rate of 14/min.
D) Symmetric chest expansion of 5 cm.
E) Pursed-lip breathing only during sleep.
Correct Answer: B) Flaring of the nostrils.
Rationale: Nasal flaring is a classic sign of respiratory distress and the use of accessory
muscles to breathe. In a client with COPD and acute dyspnea, the nurse would expect
tachypnea (increased rate), nasal flaring, pursed-lip breathing, and potentially a barrel-
shaped chest. Bradypnea (slow breathing) is not expected in a client struggling with
dyspnea.
Question 8
A nurse is teaching a client about the correct use of a cane. Which of the following instructions
should the nurse include? (Select all that apply)
A) Ensure the cane has a rubber cap.
B) Hold the cane on the weaker side.
C) Hold the cane on the stronger side.
D) Flex the elbow slightly when using the cane.
E) Use a quad cane for increased support.
, 4
Correct Answer: A, C, D, E (Multiple correct answer format presented as E in some systems,
but following the user's logic: A) Ensure the cane has a rubber cap; C) Hold the cane on the
stronger side; D) Flex the elbow slightly when using the cane; E) Use a quad cane for
increased support.)
Rationale: The cane should be held on the unaffected (stronger) side to provide the best
balance and support for the weaker leg. The elbow should be flexed 15 to 30 degrees to
allow for comfort and leverage. A rubber cap is essential to provide traction and prevent
slipping. A quad cane provides a wider base of support than a single-point cane.
Question 9
A nurse is teaching a group of assistive personnel (AP) about the expected integumentary
changes in older adults. Which of the following should the nurse include?
A) Increased subcutaneous fat.
B) Decreased in elasticity.
C) Increased production of skin oils.
D) Thickening of the dermal layer.
E) Faster nail growth.
Correct Answer: B) Decreased in elasticity.
Rationale: As skin ages, there is a loss of collagen and elastin, leading to a decrease in
elasticity (turgor) and the appearance of wrinkles. Other changes include a thinning of the
epidermis and dermis, decreased subcutaneous fat (increasing risk of cold intolerance and
pressure injuries), and decreased oil production (leading to dry, flaky skin).
Question 10
A nurse is assessing a client who reports a decrease in the effectiveness of their arthritis
medication. Which of the following factors should the nurse identify as a potential cause?
A) The client has a history of recurring bowel inflammation.
B) The client drinks 2 liters of water daily.
C) The client takes the medication with a small snack.
D) The client walks for 20 minutes every day.
E) The client sleeps in a recliner chair.
Correct Answer: A) The client has a history of recurring bowel inflammation.
Rationale: Conditions that cause inflammation of the gastrointestinal tract, such as Crohn's
disease or ulcerative colitis, can significantly impair the absorption of oral medications. If
the medication is not being absorbed efficiently in the small or large intestine due to
inflammation or increased motility, its therapeutic effectiveness will decrease.
Question 11
A nurse is monitoring a client who has been receiving intermittent enteral feedings. Which of the
following findings should the nurse identify as a manifestation of intolerance to the feeding?
Question 1
A nurse is developing a plan of care for a client who has dysphagia. Which of the following
interventions should the nurse include?
A) Provide the client with a straw for all liquids.
B) Encourage the client to tilt their head back when swallowing.
C) Have the client sit upright for 1 hr following meals.
D) Give the client thin liquids to make swallowing easier.
E) Offer the client large bites of food to stimulate the gag reflex.
Correct Answer: C) Have the client sit upright for 1 hr following meals.
Rationale: Clients with dysphagia are at high risk for aspiration pneumonia. Maintaining
an upright position (High-Fowler's or sitting in a chair) during and for at least 30 to 60
minutes after meals uses gravity to assist the passage of food into the stomach and prevents
gastric reflux and aspiration. Straws should be avoided as they can increase the risk of
aspiration by delivering too much fluid too quickly. Thin liquids are more difficult to
control for a client with dysphagia; thickened liquids are usually preferred.
Question 2
A nurse is assessing an infusion IV site and notes the client reports pain. The site is red and warm
to the touch. Which of the following actions should the nurse take?
A) Slow the infusion rate until the pain subsides.
B) Apply a cold compress to the site for 30 minutes.
C) Discontinue the infusion and remove the IV catheter.
D) Flush the catheter with 10 mL of normal saline.
E) Elevate the extremity and continue the infusion.
Correct Answer: C) Discontinue the infusion and remove the IV catheter.
Rationale: Pain, redness, and warmth at an IV site are classic manifestations of phlebitis
(inflammation of the vein). The priority action when a complication such as phlebitis,
infiltration, or extravasation is identified is to stop the infusion and remove the catheter to
prevent further tissue or vein damage. After removal, the nurse should apply a warm
compress and document the finding using a phlebitis scale.
Question 3
A nurse is performing a routine abdominal assessment for a client. Which of the following
sequences should the nurse follow?
A) Palpation, percussion, auscultation, inspection.
B) Inspection, auscultation, percussion, palpation.
C) Auscultation, inspection, palpation, percussion.
D) Inspection, palpation, percussion, auscultation.
E) Percussion, auscultation, inspection, palpation.
, 2
Correct Answer: B) Inspection, auscultation, percussion, palpation.
Rationale: The standard order of physical assessment is inspection, palpation, percussion,
and auscultation. However, for the abdomen, the sequence is modified. The nurse must
perform palpation and percussion AFTER auscultation because touching or pressing on the
abdomen can stimulate peristalsis, which would result in false or altered bowel sounds
during auscultation.
Question 4
A nurse is teaching a group of new nurses about the different types of immunity. Which of the
following information should the nurse include?
A) Passive immunity is permanent and lasts a lifetime.
B) The body produces antibodies in response to an antigen with active immunity.
C) Active immunity is acquired through the transfer of antibodies from a mother to a fetus.
D) Passive immunity occurs when a person is exposed to a live pathogen.
E) Active immunity provides immediate protection against a pathogen.
Correct Answer: B) The body produces antibodies in response to an antigen with active
immunity.
Rationale: Active immunity occurs when the body's own immune system produces
antibodies in response to exposure to a foreign antigen, either through contracting a disease
(natural active) or receiving a vaccine (artificial active). Passive immunity involves
receiving antibodies from an outside source (like maternal-fetal transfer or
immunoglobulin injections), provides immediate but temporary protection, and does not
result in the formation of memory cells.
Question 5
A nurse is assessing an older adult client for risk factors for infection. Which of the following
findings should the nurse identify as an age-related change that increases this risk?
A) Increased production of digestive enzymes.
B) Heightened inflammatory response.
C) Lowered immune system function.
D) Increased elasticity of the skin.
E) Enhanced cough reflex.
Correct Answer: C) Lowered immune system function.
Rationale: The aging process leads to "immunosenescence," which is a gradual decrease in
immune system function. Older adults have a decreased production of T-cells and B-cells,
making them more susceptible to infections and reducing their response to vaccinations.
Other factors include thinned skin (loss of protective barrier) and a decreased cough reflex,
which makes it harder to clear secretions from the lungs.
, 3
Question 6
A nurse is teaching a client about the correct use of a Metered-Dose Inhaler (MDI). Which of the
following instructions should the nurse include?
A) Exhale quickly after inhaling the medication.
B) Inhale medication deeply for 3 to 5 seconds.
C) Wait 10 seconds between puffs of the same medication.
D) Shake the inhaler for 2 seconds before use.
E) Hold the breath for 2 seconds after inhalation.
Correct Answer: B) Inhale medication deeply for 3 to 5 seconds.
Rationale: When using an MDI, the client should breathe in slowly and deeply for 3 to 5
seconds while depressing the canister to ensure the medication reaches the lower airways.
After inhalation, the client should hold their breath for about 10 seconds to allow the
medication to settle in the lungs. If a second puff is required, the client should wait 1 to 2
minutes between puffs.
Question 7
A nurse is performing a focused assessment on a client who has a history of COPD and is
experiencing dyspnea. Which of the following findings should the nurse expect?
A) Bradypnea.
B) Flaring of the nostrils.
C) A respiratory rate of 14/min.
D) Symmetric chest expansion of 5 cm.
E) Pursed-lip breathing only during sleep.
Correct Answer: B) Flaring of the nostrils.
Rationale: Nasal flaring is a classic sign of respiratory distress and the use of accessory
muscles to breathe. In a client with COPD and acute dyspnea, the nurse would expect
tachypnea (increased rate), nasal flaring, pursed-lip breathing, and potentially a barrel-
shaped chest. Bradypnea (slow breathing) is not expected in a client struggling with
dyspnea.
Question 8
A nurse is teaching a client about the correct use of a cane. Which of the following instructions
should the nurse include? (Select all that apply)
A) Ensure the cane has a rubber cap.
B) Hold the cane on the weaker side.
C) Hold the cane on the stronger side.
D) Flex the elbow slightly when using the cane.
E) Use a quad cane for increased support.
, 4
Correct Answer: A, C, D, E (Multiple correct answer format presented as E in some systems,
but following the user's logic: A) Ensure the cane has a rubber cap; C) Hold the cane on the
stronger side; D) Flex the elbow slightly when using the cane; E) Use a quad cane for
increased support.)
Rationale: The cane should be held on the unaffected (stronger) side to provide the best
balance and support for the weaker leg. The elbow should be flexed 15 to 30 degrees to
allow for comfort and leverage. A rubber cap is essential to provide traction and prevent
slipping. A quad cane provides a wider base of support than a single-point cane.
Question 9
A nurse is teaching a group of assistive personnel (AP) about the expected integumentary
changes in older adults. Which of the following should the nurse include?
A) Increased subcutaneous fat.
B) Decreased in elasticity.
C) Increased production of skin oils.
D) Thickening of the dermal layer.
E) Faster nail growth.
Correct Answer: B) Decreased in elasticity.
Rationale: As skin ages, there is a loss of collagen and elastin, leading to a decrease in
elasticity (turgor) and the appearance of wrinkles. Other changes include a thinning of the
epidermis and dermis, decreased subcutaneous fat (increasing risk of cold intolerance and
pressure injuries), and decreased oil production (leading to dry, flaky skin).
Question 10
A nurse is assessing a client who reports a decrease in the effectiveness of their arthritis
medication. Which of the following factors should the nurse identify as a potential cause?
A) The client has a history of recurring bowel inflammation.
B) The client drinks 2 liters of water daily.
C) The client takes the medication with a small snack.
D) The client walks for 20 minutes every day.
E) The client sleeps in a recliner chair.
Correct Answer: A) The client has a history of recurring bowel inflammation.
Rationale: Conditions that cause inflammation of the gastrointestinal tract, such as Crohn's
disease or ulcerative colitis, can significantly impair the absorption of oral medications. If
the medication is not being absorbed efficiently in the small or large intestine due to
inflammation or increased motility, its therapeutic effectiveness will decrease.
Question 11
A nurse is monitoring a client who has been receiving intermittent enteral feedings. Which of the
following findings should the nurse identify as a manifestation of intolerance to the feeding?
