RN ATI capstone proctored
comprehensive assessment 2019 B
EXAM
1. A nurse is assessing a client who received 2 units of packed
RBCs 48 hours ago. Which of the following findings indicates
that the therapy has been effective?
A. WBC count 12,000/mm³
B. Potassium 4.8 mEq/L
C. Hemoglobin 14.9 g/dL ✅
D. BUN 18 mg/dL
Rationale: Packed RBCs are administered to clients who have
decreased hemoglobin or hematocrit. A hemoglobin level of 14.9
g/dL is within the expected range (14–18 g/dL for males, 12–16
g/dL for females), indicating the therapy has been effective.
2. A nurse working in an emergency department is triaging
four clients. Which client should be treated first?
A. Older adult reporting constipation for 4 days
B. Preschooler with a skin rash
C. Adolescent with a closed fracture
D. Middle adult with unstable vital signs ✅
Rationale: Using the stable versus unstable approach, the client
with unstable vital signs requires immediate treatment to reduce
the risk of further injury or possible death.
,3. A nurse is caring for a client who has fluid volume
overload. Which task should the nurse delegate to the CNA?
A. Palpate the degree of edema
B. Regulate the IV pump fluid rate
C. Measure the client’s daily weight ✅
D. Assess the client’s vital signs
Rationale: Measuring a client’s daily weight is within the CNA’s
range of function and requires minimal clinical judgment, making
it appropriate for delegation while the nurse focuses on
assessment and complex tasks.
4. A nurse is preparing to administer mannitol 0.2 g/kg IV
bolus as a test dose to a client with severe oliguria. The client
weighs 198 lb. How many grams should the nurse administer?
A. 12 g
B. 15 g
C. 18 g ✅
D. 20 g
Rationale: Convert pounds to kilograms (198 lb ÷ 2.2 = 90 kg).
Then calculate: 90 kg × 0.2 g/kg = 18 g.
5. A nurse is caring for a client who had abdominal surgery 24
hours ago. Which action is the priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing ✅
D. Monitor the incision site for infection
,Rationale: Deep breathing and coughing help prevent
postoperative pneumonia by promoting lung expansion and
clearing secretions. This aligns with the ABCs (airway, breathing,
circulation) priority framework.
6. A nurse is caring for a client with hyperthyroidism. Which
of the following findings should the nurse expect?
A. Tremors ✅
B. Bradycardia
C. Cold intolerance
D. Weight gain
Rationale: Tremors are classic manifestations of hyperthyroidism,
along with tachycardia, diaphoresis, weight loss, insomnia, and
exophthalmia. Bradycardia and cold intolerance are more
indicative of hypothyroidism.
7. A nurse is assessing a school-aged child with bacterial
meningitis. Which finding should the nurse expect?
A. Hyperreflexia
B. Nuchal rigidity ✅
C. Hypotension
D. Polyphagia
Rationale: Nuchal rigidity (stiff neck) is a classic manifestation of
bacterial meningitis, along with fever, headache, photophobia,
and Kernig’s or Brudzinski’s signs. This occurs due to meningeal
inflammation and irritation.
8. A nurse is preparing to initiate IV access for an older adult
client. Which site should the nurse select?
, A. Radial vein of the inner arm ✅
B. Dorsal veins of the hand
C. Cephalic vein of the wrist
D. Basilic vein of the antecubital
Rationale: For older adults, the radial vein of the inner arm
provides adequate subcutaneous tissue and cushioning. Dorsal
hand veins may roll easily, and wrist or antecubital sites have
higher risks of movement dislodging the catheter.
9. An antepartum nurse is caring for four clients. For which
client should the nurse initiate seizure precautions?
A. 16 weeks gestation with hydatidiform mole
B. 28 weeks gestation with vaginal bleeding
C. 33 weeks gestation with severe gestational hypertension
✅
D. 36 weeks gestation with positive GBS culture
Rationale: Severe gestational hypertension increases the risk of
eclampsia (seizures). Seizure precautions include padding the bed
rails, keeping oxygen and suction equipment nearby, and
maintaining a quiet environment. The other options do not
present immediate seizure risk.
10. A nurse is preparing to assist with a thoracentesis for a
client with pleurisy. What action should the nurse plan to
take?
A. Instruct the client to avoid coughing during the procedure
✅
B. Position the client prone
comprehensive assessment 2019 B
EXAM
1. A nurse is assessing a client who received 2 units of packed
RBCs 48 hours ago. Which of the following findings indicates
that the therapy has been effective?
A. WBC count 12,000/mm³
B. Potassium 4.8 mEq/L
C. Hemoglobin 14.9 g/dL ✅
D. BUN 18 mg/dL
Rationale: Packed RBCs are administered to clients who have
decreased hemoglobin or hematocrit. A hemoglobin level of 14.9
g/dL is within the expected range (14–18 g/dL for males, 12–16
g/dL for females), indicating the therapy has been effective.
2. A nurse working in an emergency department is triaging
four clients. Which client should be treated first?
A. Older adult reporting constipation for 4 days
B. Preschooler with a skin rash
C. Adolescent with a closed fracture
D. Middle adult with unstable vital signs ✅
Rationale: Using the stable versus unstable approach, the client
with unstable vital signs requires immediate treatment to reduce
the risk of further injury or possible death.
,3. A nurse is caring for a client who has fluid volume
overload. Which task should the nurse delegate to the CNA?
A. Palpate the degree of edema
B. Regulate the IV pump fluid rate
C. Measure the client’s daily weight ✅
D. Assess the client’s vital signs
Rationale: Measuring a client’s daily weight is within the CNA’s
range of function and requires minimal clinical judgment, making
it appropriate for delegation while the nurse focuses on
assessment and complex tasks.
4. A nurse is preparing to administer mannitol 0.2 g/kg IV
bolus as a test dose to a client with severe oliguria. The client
weighs 198 lb. How many grams should the nurse administer?
A. 12 g
B. 15 g
C. 18 g ✅
D. 20 g
Rationale: Convert pounds to kilograms (198 lb ÷ 2.2 = 90 kg).
Then calculate: 90 kg × 0.2 g/kg = 18 g.
5. A nurse is caring for a client who had abdominal surgery 24
hours ago. Which action is the priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing ✅
D. Monitor the incision site for infection
,Rationale: Deep breathing and coughing help prevent
postoperative pneumonia by promoting lung expansion and
clearing secretions. This aligns with the ABCs (airway, breathing,
circulation) priority framework.
6. A nurse is caring for a client with hyperthyroidism. Which
of the following findings should the nurse expect?
A. Tremors ✅
B. Bradycardia
C. Cold intolerance
D. Weight gain
Rationale: Tremors are classic manifestations of hyperthyroidism,
along with tachycardia, diaphoresis, weight loss, insomnia, and
exophthalmia. Bradycardia and cold intolerance are more
indicative of hypothyroidism.
7. A nurse is assessing a school-aged child with bacterial
meningitis. Which finding should the nurse expect?
A. Hyperreflexia
B. Nuchal rigidity ✅
C. Hypotension
D. Polyphagia
Rationale: Nuchal rigidity (stiff neck) is a classic manifestation of
bacterial meningitis, along with fever, headache, photophobia,
and Kernig’s or Brudzinski’s signs. This occurs due to meningeal
inflammation and irritation.
8. A nurse is preparing to initiate IV access for an older adult
client. Which site should the nurse select?
, A. Radial vein of the inner arm ✅
B. Dorsal veins of the hand
C. Cephalic vein of the wrist
D. Basilic vein of the antecubital
Rationale: For older adults, the radial vein of the inner arm
provides adequate subcutaneous tissue and cushioning. Dorsal
hand veins may roll easily, and wrist or antecubital sites have
higher risks of movement dislodging the catheter.
9. An antepartum nurse is caring for four clients. For which
client should the nurse initiate seizure precautions?
A. 16 weeks gestation with hydatidiform mole
B. 28 weeks gestation with vaginal bleeding
C. 33 weeks gestation with severe gestational hypertension
✅
D. 36 weeks gestation with positive GBS culture
Rationale: Severe gestational hypertension increases the risk of
eclampsia (seizures). Seizure precautions include padding the bed
rails, keeping oxygen and suction equipment nearby, and
maintaining a quiet environment. The other options do not
present immediate seizure risk.
10. A nurse is preparing to assist with a thoracentesis for a
client with pleurisy. What action should the nurse plan to
take?
A. Instruct the client to avoid coughing during the procedure
✅
B. Position the client prone
