ATI Capstone Fundamentals Exam GRADED A LATEST
VERSION 100 QUESTINS AND ANSWERS
a nurse is assessing the pain level of a client who has dementia and difficulty communicating,
which pain assessment technique should the nurse use? -✔✔ behavioral indicators
(increased agitation, restlessness)
a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should
the nurse do first? -✔✔ recheck the clients BP
(reassess prior to any intervention)
a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify
as a cath occlusion? -✔✔ bladder distention
(inability to empty the bladder, impaired elimination)
a nurse is discussing immunity with a client who has received an immunization, the nurse
should identify that an immunization functions as part of which of the following types of
immunity? -✔✔ acquired immunity
(artificial/acquired immunity occurs when antigens from toxoids or immunizations are
ADMINISTERED to a client, once in the body, the stimulate the production of antibodies )
a nurse is reviewing the health history of an OA who has a hip fracture
the nurse should identify what is a risk of developing pressure injuries? -✔✔ urinary
incontinence
, (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction
and shear, immobility, alterations in sensory perception)
a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red
and there is warmth along the coarse of the vein, what should the nurse do? -✔✔ d/c the
infusion
(assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start
new IV)
a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in
diameter. which of the following terms should the nurse use to document this finding? -✔✔
macule
(nonpalpable smaller than 1cm, ex: freckle)
a community health nurse is teaching a group of clients about first aid for different types of
wounds. which of the following client statements indicates an understanding of the teaching? -
✔✔ i should apply clean dressings over the top of blood saturated dressings and hold pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions
should the nurse take to facilitate mourning? -✔✔ encourage the partner to ask for help when
needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal
surgery. which of the following behaviors should the nurse identify as increasing the client's risk
for constipation? -✔✔ urge suppression
history of chronic stimulant laxative use
inadequate fluid intake
VERSION 100 QUESTINS AND ANSWERS
a nurse is assessing the pain level of a client who has dementia and difficulty communicating,
which pain assessment technique should the nurse use? -✔✔ behavioral indicators
(increased agitation, restlessness)
a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should
the nurse do first? -✔✔ recheck the clients BP
(reassess prior to any intervention)
a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify
as a cath occlusion? -✔✔ bladder distention
(inability to empty the bladder, impaired elimination)
a nurse is discussing immunity with a client who has received an immunization, the nurse
should identify that an immunization functions as part of which of the following types of
immunity? -✔✔ acquired immunity
(artificial/acquired immunity occurs when antigens from toxoids or immunizations are
ADMINISTERED to a client, once in the body, the stimulate the production of antibodies )
a nurse is reviewing the health history of an OA who has a hip fracture
the nurse should identify what is a risk of developing pressure injuries? -✔✔ urinary
incontinence
, (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction
and shear, immobility, alterations in sensory perception)
a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red
and there is warmth along the coarse of the vein, what should the nurse do? -✔✔ d/c the
infusion
(assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start
new IV)
a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in
diameter. which of the following terms should the nurse use to document this finding? -✔✔
macule
(nonpalpable smaller than 1cm, ex: freckle)
a community health nurse is teaching a group of clients about first aid for different types of
wounds. which of the following client statements indicates an understanding of the teaching? -
✔✔ i should apply clean dressings over the top of blood saturated dressings and hold pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions
should the nurse take to facilitate mourning? -✔✔ encourage the partner to ask for help when
needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal
surgery. which of the following behaviors should the nurse identify as increasing the client's risk
for constipation? -✔✔ urge suppression
history of chronic stimulant laxative use
inadequate fluid intake
