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ATI Comprehensive Predictor 2025 | 300 NCLEX-Style Questions with
Rationales | Final Capstone Exam Review
1. A nurse is caring for a client who has heart failure and is prescribed furosemide.
Which of the following findings should the nurse report to the provider
immediately?
A. Blood pressure 122/80 mm Hg
B. Potassium 3.1 mEq/L
C. Urine output 1,200 mL in 8 hours
D. Weight loss of 1.3 kg in 24 hours
Answer: B. Potassium 3.1 mEq/L
Rationale: Hypokalemia is a serious adverse effect of furosemide and can lead to
cardiac arrhythmias. A potassium level of 3.1 mEq/L is below normal and must be
reported immediately.
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2. A client at 38 weeks gestation is in active labor. The nurse notes late
decelerations on the fetal heart monitor. What is the nurse's first action?
A. Increase the oxytocin infusion
B. Place the client in a lateral position
C. Perform a vaginal exam
D. Document the finding and continue monitoring
Answer: B. Place the client in a lateral position
Rationale: Late decelerations suggest uteroplacental insufficiency. The first
intervention is to improve placental perfusion by turning the client to her left side
to increase blood flow.
3. A child is admitted with suspected epiglottitis. Which of the following actions
should the nurse take first?
A. Prepare the child for a chest x-ray
B. Assess the child’s temperature
C. Obtain a throat culture
D. Notify the rapid response team
Answer: D. Notify the rapid response team
Rationale: Epiglottitis is a life-threatening emergency that can lead to sudden
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airway obstruction. The nurse must ensure emergency airway equipment is
available and call for immediate help.
4. A nurse is caring for a client receiving IV heparin for a deep vein thrombosis.
The client’s PTT is 98 seconds. What is the nurse’s priority action?
A. Continue the infusion and recheck labs in 4 hours
B. Prepare to administer protamine sulfate
C. Increase the heparin rate
D. Encourage the client to ambulate
Answer: B. Prepare to administer protamine sulfate
Rationale: A PTT of 98 seconds is above the therapeutic range and increases
bleeding risk. Protamine sulfate is the antidote for heparin toxicity.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings requires immediate intervention?
A. Acrocyanosis
B. Heart rate of 150 bpm
C. Grunting with nasal flaring
D. Positive Moro reflex
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Answer: C. Grunting with nasal flaring
Rationale: These are signs of respiratory distress in a newborn and must be
addressed immediately to prevent complications like hypoxia.
6. A nurse is teaching a client who has a new prescription for digoxin. Which
statement by the client indicates a need for further teaching?
A. “I will check my pulse before taking the medication.”
B. “I will call my provider if I see yellow spots.”
C. “I will take the medication with food.”
D. “If I miss a dose, I can double up later.”
Answer: D. “If I miss a dose, I can double up later.”
Rationale: Clients should never double up on digoxin due to its narrow therapeutic
index and risk of toxicity.
7. A nurse is caring for a client with a pressure ulcer on the sacrum that has slough
and eschar. Which stage is this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
ATI Comprehensive Predictor 2025 | 300 NCLEX-Style Questions with
Rationales | Final Capstone Exam Review
1. A nurse is caring for a client who has heart failure and is prescribed furosemide.
Which of the following findings should the nurse report to the provider
immediately?
A. Blood pressure 122/80 mm Hg
B. Potassium 3.1 mEq/L
C. Urine output 1,200 mL in 8 hours
D. Weight loss of 1.3 kg in 24 hours
Answer: B. Potassium 3.1 mEq/L
Rationale: Hypokalemia is a serious adverse effect of furosemide and can lead to
cardiac arrhythmias. A potassium level of 3.1 mEq/L is below normal and must be
reported immediately.
, 2
2. A client at 38 weeks gestation is in active labor. The nurse notes late
decelerations on the fetal heart monitor. What is the nurse's first action?
A. Increase the oxytocin infusion
B. Place the client in a lateral position
C. Perform a vaginal exam
D. Document the finding and continue monitoring
Answer: B. Place the client in a lateral position
Rationale: Late decelerations suggest uteroplacental insufficiency. The first
intervention is to improve placental perfusion by turning the client to her left side
to increase blood flow.
3. A child is admitted with suspected epiglottitis. Which of the following actions
should the nurse take first?
A. Prepare the child for a chest x-ray
B. Assess the child’s temperature
C. Obtain a throat culture
D. Notify the rapid response team
Answer: D. Notify the rapid response team
Rationale: Epiglottitis is a life-threatening emergency that can lead to sudden
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airway obstruction. The nurse must ensure emergency airway equipment is
available and call for immediate help.
4. A nurse is caring for a client receiving IV heparin for a deep vein thrombosis.
The client’s PTT is 98 seconds. What is the nurse’s priority action?
A. Continue the infusion and recheck labs in 4 hours
B. Prepare to administer protamine sulfate
C. Increase the heparin rate
D. Encourage the client to ambulate
Answer: B. Prepare to administer protamine sulfate
Rationale: A PTT of 98 seconds is above the therapeutic range and increases
bleeding risk. Protamine sulfate is the antidote for heparin toxicity.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings requires immediate intervention?
A. Acrocyanosis
B. Heart rate of 150 bpm
C. Grunting with nasal flaring
D. Positive Moro reflex
, 4
Answer: C. Grunting with nasal flaring
Rationale: These are signs of respiratory distress in a newborn and must be
addressed immediately to prevent complications like hypoxia.
6. A nurse is teaching a client who has a new prescription for digoxin. Which
statement by the client indicates a need for further teaching?
A. “I will check my pulse before taking the medication.”
B. “I will call my provider if I see yellow spots.”
C. “I will take the medication with food.”
D. “If I miss a dose, I can double up later.”
Answer: D. “If I miss a dose, I can double up later.”
Rationale: Clients should never double up on digoxin due to its narrow therapeutic
index and risk of toxicity.
7. A nurse is caring for a client with a pressure ulcer on the sacrum that has slough
and eschar. Which stage is this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
