RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT FORM C ACTUAL TEST 2023 WITH VERIFIED SOLUTIONS/A+ GRADE

A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following should the actions the nurse take?: Document the client's
condition every 15 minutes
2. A nursing planning care for a school-age child who is 4 hr postoperative
following perforated appendicitis. Which of the following actions should the
nurse include in the plan of care?: Administer analgesics on a scheduled basis
for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of
the following clients should the nurse plan to assess first?: A client who has
a hip fracture and a new onset of tachypnea
4. A nurse is preparing to apply a transdermal nicotine patch for a client.
Which of the following actions should the nurse take?: Wear gloves to apply
the patch to the client's skin
5. A nurse has just received change-of-shift report for four clients. Which of
the following clients should the nurse assess first?: A client who was just given
a glass of orange juice for a low blood glucose level
6. A nurse is caring for a client who is receiving intermittent enteral tube
feedings. Which of the following places the client at risk for aspiration?: A
history of gastroesophageal reflux disease
7. A nurse is reviewing the laboratory results for a client who has Cushing's
disease. The nurse should expect the client to have an increase in which of
the following laboratory values?: Serum glucose level- increased
8. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium
sulfate after the client displaces toxicity. Which of the following actions
should the nurse take?: Administer calcium gluconate IV
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have
an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
9. A charge nurse is teaching new staff members about factors that increase
a client's risk to become violent. Which of the following risk factors should
the nurse include as the best predictor of future violence?: Previous violent
behavior
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RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT
FORM C ACTUAL TEST 2023 WITH VERIFIED SOLUTIONS/A+
GRADE
Risk factors also include: past history of aggression, poor impulse control, and
violence. Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders).
10. A nurse is preparing to perform a sterile dressing change. Which of
the following actions should the nurse take when setting up the sterile
field?: Place the cap from the solution sterile side up on clean surface
11. A nurse is providing teaching to an older adult client about methods to
promote nighttime
sleep. Which of the following instructions should the nurse include?: Eat a
light snack before bedtime
12. A home health nurse is preparing for an initial visit with an older adult
client who lives
alone. Which of the following actions should the nurse take first?: Identify
environmental hazards in the home
13. A nurse is assessing the remote memory of an older adult client who has
mild dementia. Which of the following questions should the nurse ask the
client?: "What high school did you graduate from"
14. A nurse is providing teaching to an adolescent who has type 1 diabetes
mellitus. Which of the following goals should the nurse include in the teaching?: HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management
of grand mal seizures and has a new prescription for isoniazid and rifampin.
Which of the following should the nurse conclude if the client develops ataxia
and incoordination?: The client is showing evidence of phenytoin toxicity
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by
the nurse?: Increase in frequency of swallowing (may indicate bleeding)
17. A nurse is planning care for a preschool-age child who is in the acute
phase Kawasaki disease. Which of the following interventions should the
nurse include in the plan of care?: Monitor the child's cardiac status
18. A nurse is planning an educational program for high school students
about cigarette smoking. Which of the following potential consequences of
smoking is most likely to discourage adolescents from using tobacco?: Use
of tobacco decreases the level of athletic ability
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RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT
FORM C ACTUAL TEST 2023 WITH VERIFIED SOLUTIONS/A+
GRADE
19. A nurse is assessing a client who is prescribed spironolactone. Which of
the following laboratory values should the nurse monitor for this client?: -
Serum potassium- diuretic that retains potassium= hyperkalemic risk
20. A nurse has agreed to serve as an interpreter for an older adult client
who is assigned to another nurse. Which of the following statements by the
nurse indicates an understanding of this role?: "I will let the client know that I
am available as the interpreter."
21. A nurse is performing assessments on newborns in the nursery. Which
of the following findings should the nurse report to the provider?: A two day
old newborn who has a respiratory rate of 70
(30 - 60 is normal)
22. A nurse on an acute unit has received change of shift report for 4 clients
which of the following clients should the nurse assess first? Pain pallor
pulselessness paresthesia: A client who has fractured left tibia and pallor in the
affected extremity
23. A nurse is providing discharge instructions to a client who has a new
prescription for haloperidol which of the following adverse effects should
the nurse instruct the client to report to the provider?: Shuffling gait ’A/E EPS:
is an indication of parkinsonism and should be reported
24. A nurse is planning discharge teaching about cord care for the parents
of a newborn which of the following instructions should the nurse plan to
include in the teaching?: Keep the cord stump dry until it falls off
Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water.
Cord is expected to turn black and dry
25. A nurse is teaching dietary guidelines to a client who has celiac disease
which of the following food choices is appropriate for the client?: Potato
pancakes
26. A nurse is working in acute care mental health facility is assessing a
client who has
schizophrenia. Which of the following findings should the nurse expect?: -
Disorganized speech
27. A nurse is caring for a client who is immobile which of the following
interventions is appropriate to prevent contracture?: Apply an orthotic to the
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RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT
FORM C ACTUAL TEST 2023 WITH VERIFIED SOLUTIONS/A+
GRADE
clients foot
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28. A public health nurse working in a rural area is developing a program
to improve health for the local population. Which of the following actions
should the nurse plan to take?: Provide anticipatory guidance classes to parents
through public schools
29. A nurse in the emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?: Below the knee
amputation
30. A nurse is preparing a change of shift report for an adult female client
who is postoperative. Which of the following client information should the
nurse include in the report?: Platelets 100,000/mm3
(150,000-300,00 risk for bleeding)
31. A nurse is admitting a client who has anorexia nervosa. Which of the
following is an expected finding?: Prealbumin 10 mcg/dl
(normal: 16-40)
32. A charge nurse on a medical-surgical unit is planning assignments for a
licensed practical nurse (LPN) who has been sent from the postpartum unit
due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?: A client who is postoperative
following a bowel resection with an NGT set to continuous suction
33. A nurse is caring for a client who is at 41 week of gestation and is
receiving oxytocin for labor induction. The nurse notes early deceleration on
the fetal heart rate monitor . Which of the following nursing actions should
the nurse take ?: Continue the monitor the fetal heart rate
(Not a problem- absent or late are a
problem)
34. A nurse is conducting an initial assessment of a client and noticed a
discrepancy between the clients current IV infusion and the information
received during the shift report. Which of the following actions should the
nurse take?: Compare the current infusion with the prescription in the client's
medication record.
35. A nurse is reviewing the medical record of a client who has schizophrenia
and is taking clozapine. Which of the following findings should the nurse
identify as a contraindication to the administration of clozapine ?: WBC count
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2,900 /mm3
(Agrunlocytosis - 4,800-15,000 normal range)
36. A nurse is caring for a client who is at 38 weeks of gestation and has a
history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?: You may
breastfeed unless your nipples are cracked or bleeding.
37. A nurse is caring for a client who has returned to the medical-surgical unit
following a transurethral resection of the prostate. Which of the following
should the nurse identify as priority nursing assessment after reviewing the
clients information?: Level of consciousness.
(priority)- decreased LOC can mean less o2 going to the brain ?
38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ?: Initiate seizure precautions
39. A nurse manager is updating protocols for belt restraints. Which of the
following guidelines should the nurse include.: Document the client's conditions every 15 minutes
40. A nurse in emergency department is caring for a client who has full
thickness burn of the thorax and upper torso. After securing the client's
airway, which of the following is the nurse's priority intervention?: Iniang IV
1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing
41. A nurse is caring for a client who has cancer and is being transferred to
hospice care. The client's daughter tells the nurse, "I'm not sure what to say
to my mom if she asks me about dying." which of the following responses
by the nurse is appropriate? (SATA): - Let's talk about your mom's cancer and
how things will progress from here.
- Tell me how you are feeling about your mom dying.
- You sound like you have questions about your mom dying. Let's talk about it.
42. A nurse is reviewing the medical records of four clients. The nurse should
identify that which of the following client findings follow up care?: A client
who received a Mantoux test 48 hours ago and has induration
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43. A community health nurse receives a referral for a family home visit.
Which of the following tasks should the nurse perform first?: Clarify the
source of the referral
44. A nurse is caring for a client who will undergo a procedure. The client
states he does not want the provider to discuss the results with his partner.
Which of the following is an appropriate response for the nurse to make?: You
have the right to decide who receives information
45. A nurse is discussing a weight loss with a client who is concerned about
losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should
identify the weight of the following total percentage?: 7.5%
46. A nurse is caring for a client who is 4 hr postpartum and reports that
she cannot urinate. Which of the following interventions should the nurse
implement?: Pour water from a squeeze bottle over the client's perineal area.
47. A nurse is providing discharge teaching to a client who has cancer and
a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the
following instructions should the nurse include in the teaching?: Avoid hot
tub while wearing the patch
48. A nurse working on a surgical unit is developing a care plan for a client
who has paraplegia. The client has an area of non-blanchable erythema over
his ischium. Which of the following interventions should the nurse include
in the care plan?: Teach the client to shift his weight every 15 min while sitting
(cannot do this because he is paraplegic)
49. A nurse is working with a client who has an anxiety disorder and is in
the orientation phase of the therapeutic relationship. Which of the following
statements should the nurse make during this phase?: We should establish
our roles in the initial session.
50. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps
into the box on the right, placing them in the selected order of performance.
Use all steps): 1. Transport the client to another area of the nursing unit
2. Activate the facility's fire alarm system
3. Close all nearby windows and doors
4. Use the unit's fire extinguisher to attempt to put out the fire
51. A nurse is providing discharge teaching to a client who has a new
prescription for phenelzine. The nurse should instruct the client that it is safe
RN ATI Capstone Proctored Comprehensive Assessment Test C Actual Test Ques & Ans
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to eat which of the following foods while taking this medication?: Whole grain
bread
52. A nurse is caring for a client who is experiencing mild anxiety. Which of
the following findings should the nurse expect?: Heightened perceptual field
53. A nurse is caring for a client who has type 1 diabetes mellitus. The client
reports that she is not feeling well. Which of the following findings should
indicate to the nurse that the client is hypoglycemic? (SATA): Tremors
Diaphoresis
Inability to concentrate
54. A nurse is caring for an infant who has coarctation of the aorta. Which of
the following should the nurse identify as an expected finding?: Weak femoral
pulses
55. A community health nurse is planning primary prevention activities to
reduce the occurrence of abuse. Which of the following strategies should
the nurse include in the plan?
Primary - before it happens
Secondary - screening
Tertiary - already happened: Teach parenting skills to families at risk for abuse
56. A nurse and an assistive personnel (AP) are caring for a group of clients.
Which of the following tasks is appropriate for the nurse to delegate to the
AP?: Applying a condom catheter for a client who has a spinal cord injury
57. A nurse is providing teaching to an adolescent who has peptic ulcer
disease. Which of the following statements by the client indicates an understanding of the teaching?: "I will avoid food and beverages that contain caffeine"
58. A nurse is caring for a client who reports xerostomia following radiation
therapy to the mandible. Which of the following is an appropriate action by
the nurse?: Instruct the client on the use of esophageal speech
(I think)
59. A nurse is caring for four clients. Which of the following tasks can the
nurse delegate to
an assistive personnel?: Perform chest compressions during cardiac resuscitation
60. A nurse is caring for a client who states he recently purchased lavender
oil to use when he gets the flu. The nurse should recognize which of the
RN ATI Capstone Proctored Comprehensive Assessment Test C Actual Test Ques & Ans
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following findings is a potential contraindication for using lavender?: The
client has a history of asthma
61. A nurse is caring for a client who has major depressive disorder and a
new prescription for amitriptyline. The nurse should monitor for which of the
following adverse effects?: Urinary retention
62. A nurse is conducting a health promotion class about the use of oral
contraceptives. Which of the following disorders is a contraindication for oral
contraceptive use?: Hypertension
63. A nurse is preparing to witness a client's signature on a consent form for
a colon resection. The nurse should recognize that which of the following
information should be provided to the client by the provider before signing
the form? (SATA): - Explain the procedure
- Expected outcome of the procedure
- Potential complications
- Possible alternative treatments
64. A nurse is providing teaching to a client who will undergo a magnetic
resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching?: "You should not have this procedure if you are
allergic to iodine."
65. A nurse is caring for a child who has sickle cell anemia and experiencing
vaso- constrictive crisis. Which of the following actions should the nurse
include in the plan of care?: Initiate IV fluid replacement
66. A nurse is caring for an adult client who has chronic anemia and is
scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the
following actions should the nurse take?: Flush the blood administration tubing
with 0.9% sodium chloride prior to the transfusion
67. A nurse is caring for a client who is dissatisfied with the care from
the provider and decides to leave the facility against medical advice. After
notifying the provider, which of the following actions is appropriate for the
nurse to take?: Explain the risks of leaving
68. A nurse is making an initial postpartum home visit. Which of the following
client statements should the nurse identify as a manifestation of increased
RN ATI Capstone Proctored Comprehensive Assessment Test C Actual Test Ques & Ans
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risk for child abuse?: "I think the baby should be sleeping through the night by
now.
69. A nurse is caring for an infant who has gastroenteritis. Which of the
following assessments should the nurse report to the provider?: Sunken
fontanels and dry mucous membranes
70. A nurse is admitting a client who is 1 week postpartum and reports
excessive vaginal bleeding, The nurse does not speak the same language as
the client . The client partner and a 10 year old child are accompanying her.
Which of the following actions should the nurse take to gather the clients
information?: Request a female translator interpreter through the facility
71. A nurse is caring for a client who has pernicious anemia, Which of the
following laboratory values should the nurse evaluate effectiveness of the
treatment ?: Vitamin b12 level
72. A nurse is assigning tasks to assistive personnel(AP). Which of the
following tasks should the nurse assign to the AP?: Perform post mortem care
73. A nurse is caring for a client who is postpartum and reports difficulty
voiding. Which of the following findings should indicate to the nurse that the
client's ability to eliminate urine from the bladder is restored?: Two voids of
150 mL each over the past 2 hours= 2 x 30 = 60 mls
74. A nurse is caring for a client who has acute glomerulonephritis .Which
of the following should the nurse expect ?: Hematuria - urinalysis will show red
blood cells and protein, also reddish brown col colored urine
75. A nurse is providing teaching to a client about the adverse effects of
sertraline. Which of
the following effects should the nurse include ?: Excessive sweating
76. A nurse is providing teaching to the parents of a newborn about genetic
screening. Which of the following statements should the nurse include in the
teaching?: This test should be performed after you baby is 24 hours old
77. A nurse is caring for a child who has cystic fibrosis and requires postural
drainage. Which of the following actions should the nurse take?: Perform the
procedure twice a day
78. A nurse is preparing an inservice for a group of nurses about malpractice
issues in nursing. Which of the following examples should the nurse include
in the teaching?: Administering potassium via IV bolus