ATI RN CAPSTONE PROCTORED EXAM
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES GRADED A+
LATEST
1. A nurse is caring for a client who is postoperative following abdominal
surgery and reports increasing pain 6 hours after receiving IV morphine. The
nurse notes that the client’s respirations are 10/min and oxygen saturation is
90%. Which action should the nurse take first?
A. Administer naloxone
B. Encourage deep breathing and coughing
C. Decrease the morphine infusion rate
D. Assist the client to a side-lying position
Answer: C
Rationale: The priority is to manage respiratory depression related to opioid
administration. Decreasing the infusion rate is the immediate action before giving
naloxone.
,2. A client with congestive heart failure reports weight gain of 3 lb in 2 days,
increased shortness of breath, and swelling of ankles. Which nursing
intervention is most appropriate?
A. Administer a PRN dose of furosemide
B. Notify the healthcare provider
C. Encourage the client to drink more water
D. Increase the client’s activity level
Answer: B
Rationale: These findings indicate fluid overload and worsening CHF; the
provider must be notified promptly for possible medication adjustment.
3. A nurse is caring for a client with a new tracheostomy. Which finding
requires immediate intervention?
A. Mild bleeding around the stoma
B. Thick, white secretions in the tube
C. Client coughing and producing sputum
D. Oxygen saturation of 88%
Answer: D
Rationale: Oxygen saturation of 88% indicates hypoxia and requires immediate
intervention, including suctioning, repositioning, and oxygen adjustment.
,4. A client with diabetes mellitus reports nausea, vomiting, and abdominal
pain. Blood glucose is 420 mg/dL and ketones are present in urine. What is the
nurse’s priority action?
A. Administer regular insulin per sliding scale
B. Provide a high-protein snack
C. Encourage oral fluids
D. Notify the healthcare provider
Answer: A
Rationale: The priority is to treat hyperglycemia and ketosis with IV or regular
insulin to prevent DKA progression.
5. A client is admitted with pneumonia and is receiving IV antibiotics. The
client reports itching and develops hives. What should the nurse do first?
A. Discontinue the antibiotic infusion
B. Administer diphenhydramine
C. Notify the provider
D. Obtain a serum allergy panel
Answer: A
Rationale: Hives indicate an allergic reaction. The antibiotic infusion must be
stopped immediately to prevent progression to anaphylaxis.
6. A client with chronic kidney disease has an order for potassium 60 mEq PO
daily. The client’s potassium is 6.2 mEq/L. What should the nurse do?
A. Administer the potassium as ordered
B. Hold the potassium and notify the provider
C. Encourage the client to eat bananas
D. Increase the client’s fluid intake
Answer: B
Rationale: A potassium of 6.2 is high and dangerous; potassium should be held
and the provider notified immediately.
, 7. A client is receiving heparin therapy for a DVT. The nurse notes the client
has gum bleeding and petechiae. What is the nurse’s priority action?
A. Reduce the heparin dose
B. Notify the provider
C. Apply pressure to the gums
D. Check the aPTT
Answer: B
Rationale: Signs of bleeding require immediate notification. Heparin should be
held until further orders.
8. A nurse is caring for a client with newly diagnosed COPD. Which statement
indicates the client understands the teaching?
A. “I will avoid using my inhaler when I feel short of breath.”
B. “I will stop smoking and avoid smoke exposure.”
C. “I will limit activity to prevent fatigue.”
D. “I should take antibiotics daily to prevent infections.”
Answer: B
Rationale: Smoking cessation and avoiding smoke are essential to COPD
management.
9. A client with a history of MI reports chest pain rated 8/10. ECG shows ST-
elevation. What is the nurse’s immediate action?
A. Administer nitroglycerin sublingually
B. Administer aspirin 325 mg
C. Prepare the client for thrombolytic therapy
D. Assess vital signs and oxygen saturation
Answer: D
Rationale: The priority is assessment to determine stability and need for
immediate interventions.
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES GRADED A+
LATEST
1. A nurse is caring for a client who is postoperative following abdominal
surgery and reports increasing pain 6 hours after receiving IV morphine. The
nurse notes that the client’s respirations are 10/min and oxygen saturation is
90%. Which action should the nurse take first?
A. Administer naloxone
B. Encourage deep breathing and coughing
C. Decrease the morphine infusion rate
D. Assist the client to a side-lying position
Answer: C
Rationale: The priority is to manage respiratory depression related to opioid
administration. Decreasing the infusion rate is the immediate action before giving
naloxone.
,2. A client with congestive heart failure reports weight gain of 3 lb in 2 days,
increased shortness of breath, and swelling of ankles. Which nursing
intervention is most appropriate?
A. Administer a PRN dose of furosemide
B. Notify the healthcare provider
C. Encourage the client to drink more water
D. Increase the client’s activity level
Answer: B
Rationale: These findings indicate fluid overload and worsening CHF; the
provider must be notified promptly for possible medication adjustment.
3. A nurse is caring for a client with a new tracheostomy. Which finding
requires immediate intervention?
A. Mild bleeding around the stoma
B. Thick, white secretions in the tube
C. Client coughing and producing sputum
D. Oxygen saturation of 88%
Answer: D
Rationale: Oxygen saturation of 88% indicates hypoxia and requires immediate
intervention, including suctioning, repositioning, and oxygen adjustment.
,4. A client with diabetes mellitus reports nausea, vomiting, and abdominal
pain. Blood glucose is 420 mg/dL and ketones are present in urine. What is the
nurse’s priority action?
A. Administer regular insulin per sliding scale
B. Provide a high-protein snack
C. Encourage oral fluids
D. Notify the healthcare provider
Answer: A
Rationale: The priority is to treat hyperglycemia and ketosis with IV or regular
insulin to prevent DKA progression.
5. A client is admitted with pneumonia and is receiving IV antibiotics. The
client reports itching and develops hives. What should the nurse do first?
A. Discontinue the antibiotic infusion
B. Administer diphenhydramine
C. Notify the provider
D. Obtain a serum allergy panel
Answer: A
Rationale: Hives indicate an allergic reaction. The antibiotic infusion must be
stopped immediately to prevent progression to anaphylaxis.
6. A client with chronic kidney disease has an order for potassium 60 mEq PO
daily. The client’s potassium is 6.2 mEq/L. What should the nurse do?
A. Administer the potassium as ordered
B. Hold the potassium and notify the provider
C. Encourage the client to eat bananas
D. Increase the client’s fluid intake
Answer: B
Rationale: A potassium of 6.2 is high and dangerous; potassium should be held
and the provider notified immediately.
, 7. A client is receiving heparin therapy for a DVT. The nurse notes the client
has gum bleeding and petechiae. What is the nurse’s priority action?
A. Reduce the heparin dose
B. Notify the provider
C. Apply pressure to the gums
D. Check the aPTT
Answer: B
Rationale: Signs of bleeding require immediate notification. Heparin should be
held until further orders.
8. A nurse is caring for a client with newly diagnosed COPD. Which statement
indicates the client understands the teaching?
A. “I will avoid using my inhaler when I feel short of breath.”
B. “I will stop smoking and avoid smoke exposure.”
C. “I will limit activity to prevent fatigue.”
D. “I should take antibiotics daily to prevent infections.”
Answer: B
Rationale: Smoking cessation and avoiding smoke are essential to COPD
management.
9. A client with a history of MI reports chest pain rated 8/10. ECG shows ST-
elevation. What is the nurse’s immediate action?
A. Administer nitroglycerin sublingually
B. Administer aspirin 325 mg
C. Prepare the client for thrombolytic therapy
D. Assess vital signs and oxygen saturation
Answer: D
Rationale: The priority is assessment to determine stability and need for
immediate interventions.
