RN ATI CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT 2024/2025 FORM A AND B ACTUAL EXAM 350
QUESTIONS AND CORRECT DETAILED ANSWERS
A nurse is preparing to administer medication to a client who has a
nasogastric (NG) tube. Which of the following actions should the nurse take?
A) Mix all medications together before administration.
B) Administer medications with the client in a supine position.
C) Flush the NG tube with 30 mL of water before and after each medication.
D) Crush enteric-coated tablets for easier administration.
E) Use sterile water for flushing.
Correct Answer: C) Flush the NG tube with 30 mL of water before and
after each medication.
Rationale: Flushing the NG tube before and after each medication,
and between multiple medications, helps prevent clogging and
ensures the full dose reaches the stomach. The client should be in a
semi-Fowler's position to prevent aspiration. Enteric-coated tablets
should not be crushed.
Question 2
A nurse is caring for a client who is 2 days postoperative following an
abdominal hysterectomy. The client reports abdominal pain rated 8 on a 0-10
scale. The nurse assesses the client and notes a distended abdomen and
absent bowel sounds. Which of the following actions should the nurse take
first?
A) Administer a prescribed opioid analgesic.
B) Encourage the client to ambulate.
C) Obtain an order for a nasogastric tube insertion.
D) Notify the provider of the findings.
E) Provide a warm compress to the abdomen.
Correct Answer: D) Notify the provider of the findings.
Rationale: The client's symptoms (severe pain, distended abdomen,
absent bowel sounds 2 days post-op) suggest a potentially serious
complication like a paralytic ileus or bowel obstruction, which
requires immediate medical evaluation and intervention. While pain
relief is important, addressing the underlying cause takes priority
after notifying the provider.
Question 3
A nurse is caring for a client who has hyperkalemia with an ECG showing
peaked T waves. Which of the following medications should the nurse
anticipate administering first?
A) Furosemide
,B) Regular insulin and dextrose
C) Sodium polystyrene sulfonate (Kayexalate)
D) Calcium gluconate
E) Sodium bicarbonate
Correct Answer: D) Calcium gluconate
Rationale: In hyperkalemia with ECG changes (like peaked T waves,
widened QRS), calcium gluconate is administered first to stabilize
the cardiac cell membranes and prevent life-threatening
arrhythmias. It does not lower potassium levels but protects the
heart. Other medications (insulin/dextrose, Kayexalate, furosemide)
lower potassium but act more slowly.
Question 4
A nurse is providing discharge teaching to a client who has a new
prescription for warfarin. Which of the following statements indicates an
understanding of the teaching?
A) "I will increase my intake of green leafy vegetables."
B) "I will take aspirin for headaches."
C) "I will get my INR checked regularly."
D) "I will stop taking the medication if I have bleeding gums."
E) "I will use an electric razor for shaving."
Correct Answer: C) "I will get my INR checked regularly."
Rationale: Warfarin therapy requires regular monitoring of the
International Normalized Ratio (INR) to ensure the medication is
within a therapeutic range and to adjust dosages as needed. Green
leafy vegetables (high in Vitamin K) can alter warfarin's
effectiveness, aspirin increases bleeding risk, and stopping the
medication without medical advice is dangerous.
Question 5
A nurse is teaching a client who has a new diagnosis of type 1 diabetes
mellitus about managing hypoglycemia. Which of the following foods should
the nurse recommend the client consume if experiencing a hypoglycemic
episode?
A) 4 oz (120 mL) of diet soda
B) 1 slice of whole-wheat toast
C) 1/2 cup (120 mL) of fruit juice
D) 1 tablespoon of peanut butter
E) 1 cup of milk
Correct Answer: C) 1/2 cup (120 mL) of fruit juice
Rationale: For hypoglycemia, a rapidly absorbed carbohydrate source
,(15g rule) is recommended. 1/2 cup (120 mL) of fruit juice or regular
soda (not diet) provides approximately 15g of carbohydrates to
quickly raise blood glucose. Whole-wheat toast and peanut butter
are slower-acting carbohydrates or contain fat that slows
absorption.
Question 6
A nurse is caring for an older adult client who is prescribed multiple
medications. Which of the following physiological changes should the nurse
recognize as a factor that increases the risk of medication toxicity in older
adults?
A) Increased gastric motility
B) Increased hepatic blood flow
C) Decreased renal function
D) Increased lean body mass
E) Increased serum albumin levels
Correct Answer: C) Decreased renal function
Rationale: Aging often leads to decreased renal function (reduced
glomerular filtration rate), which impairs the kidneys' ability to
excrete medications. This can lead to drug accumulation and
increased risk of toxicity. Other changes like decreased hepatic
blood flow and decreased lean body mass also contribute to altered
drug pharmacokinetics in older adults.
Question 7
A nurse is assessing a 4-year-old child at a well-child visit. Which of the
following developmental milestones should the nurse expect to observe?
A) Ties shoelaces independently.
B) Rides a tricycle.
C) Copies a square.
D) Prints own name.
E) Counts to 20.
Correct Answer: B) Rides a tricycle.
Rationale: By 4 years old, children typically have the gross motor
skills to ride a tricycle. Copying a square (around 4-5 years) is a fine
motor skill that might be developing. Tying shoelaces and printing
their name are generally later milestones (5-6+ years), as is
counting to 20 (often 5+ years).
Question 8
A nurse is preparing to administer an opioid analgesic to a client. Which of
, the following assessments should the nurse perform first?
A) Blood pressure
B) Pain level
C) Respiratory rate
D) Level of consciousness
E) Bowel sounds
Correct Answer: C) Respiratory rate
Rationale: Opioid analgesics can cause respiratory depression. The
nurse's priority assessment before administering an opioid is to
check the client's respiratory rate, as a dangerously low rate (e.g.,
<12 breaths/min) may contraindicate or require dose adjustment of
the medication.
Question 9
A nurse is caring for a client who is postoperative and has a new prescription
for a clear liquid diet. Which of the following foods should the nurse offer?
A) Cream of mushroom soup
B) Applesauce
C) Sherbet
D) Gelatin
E) Milk
Correct Answer: D) Gelatin
Rationale: A clear liquid diet consists of foods that are transparent
and liquid at room temperature. Gelatin is a clear liquid. Cream
soups, applesauce, sherbet, and milk are not clear liquids.
Question 10
A nurse is providing teaching to a client who has a new colostomy. Which of
the following statements should the nurse include in the teaching?
A) "Change the ostomy appliance daily."
B) "Empty the ostomy bag when it is half full."
C) "You should expect the stoma to be pale and dry."
D) "Cut the skin barrier opening 1/2 inch larger than the stoma."
E) "It is normal to experience some leakage around the stoma."
Correct Answer: B) "Empty the ostomy bag when it is half full."
Rationale: The ostomy bag should be emptied when it is 1/3 to 1/2 full
to prevent leakage and avoid excessive weight pulling on the
appliance. The stoma should be moist and pink/red. The skin barrier
should be cut precisely to fit the stoma, leaving only 1/8 inch around
the stoma to protect the skin. Leakage is not normal and indicates
an issue with the appliance or skin barrier.
ASSESSMENT 2024/2025 FORM A AND B ACTUAL EXAM 350
QUESTIONS AND CORRECT DETAILED ANSWERS
A nurse is preparing to administer medication to a client who has a
nasogastric (NG) tube. Which of the following actions should the nurse take?
A) Mix all medications together before administration.
B) Administer medications with the client in a supine position.
C) Flush the NG tube with 30 mL of water before and after each medication.
D) Crush enteric-coated tablets for easier administration.
E) Use sterile water for flushing.
Correct Answer: C) Flush the NG tube with 30 mL of water before and
after each medication.
Rationale: Flushing the NG tube before and after each medication,
and between multiple medications, helps prevent clogging and
ensures the full dose reaches the stomach. The client should be in a
semi-Fowler's position to prevent aspiration. Enteric-coated tablets
should not be crushed.
Question 2
A nurse is caring for a client who is 2 days postoperative following an
abdominal hysterectomy. The client reports abdominal pain rated 8 on a 0-10
scale. The nurse assesses the client and notes a distended abdomen and
absent bowel sounds. Which of the following actions should the nurse take
first?
A) Administer a prescribed opioid analgesic.
B) Encourage the client to ambulate.
C) Obtain an order for a nasogastric tube insertion.
D) Notify the provider of the findings.
E) Provide a warm compress to the abdomen.
Correct Answer: D) Notify the provider of the findings.
Rationale: The client's symptoms (severe pain, distended abdomen,
absent bowel sounds 2 days post-op) suggest a potentially serious
complication like a paralytic ileus or bowel obstruction, which
requires immediate medical evaluation and intervention. While pain
relief is important, addressing the underlying cause takes priority
after notifying the provider.
Question 3
A nurse is caring for a client who has hyperkalemia with an ECG showing
peaked T waves. Which of the following medications should the nurse
anticipate administering first?
A) Furosemide
,B) Regular insulin and dextrose
C) Sodium polystyrene sulfonate (Kayexalate)
D) Calcium gluconate
E) Sodium bicarbonate
Correct Answer: D) Calcium gluconate
Rationale: In hyperkalemia with ECG changes (like peaked T waves,
widened QRS), calcium gluconate is administered first to stabilize
the cardiac cell membranes and prevent life-threatening
arrhythmias. It does not lower potassium levels but protects the
heart. Other medications (insulin/dextrose, Kayexalate, furosemide)
lower potassium but act more slowly.
Question 4
A nurse is providing discharge teaching to a client who has a new
prescription for warfarin. Which of the following statements indicates an
understanding of the teaching?
A) "I will increase my intake of green leafy vegetables."
B) "I will take aspirin for headaches."
C) "I will get my INR checked regularly."
D) "I will stop taking the medication if I have bleeding gums."
E) "I will use an electric razor for shaving."
Correct Answer: C) "I will get my INR checked regularly."
Rationale: Warfarin therapy requires regular monitoring of the
International Normalized Ratio (INR) to ensure the medication is
within a therapeutic range and to adjust dosages as needed. Green
leafy vegetables (high in Vitamin K) can alter warfarin's
effectiveness, aspirin increases bleeding risk, and stopping the
medication without medical advice is dangerous.
Question 5
A nurse is teaching a client who has a new diagnosis of type 1 diabetes
mellitus about managing hypoglycemia. Which of the following foods should
the nurse recommend the client consume if experiencing a hypoglycemic
episode?
A) 4 oz (120 mL) of diet soda
B) 1 slice of whole-wheat toast
C) 1/2 cup (120 mL) of fruit juice
D) 1 tablespoon of peanut butter
E) 1 cup of milk
Correct Answer: C) 1/2 cup (120 mL) of fruit juice
Rationale: For hypoglycemia, a rapidly absorbed carbohydrate source
,(15g rule) is recommended. 1/2 cup (120 mL) of fruit juice or regular
soda (not diet) provides approximately 15g of carbohydrates to
quickly raise blood glucose. Whole-wheat toast and peanut butter
are slower-acting carbohydrates or contain fat that slows
absorption.
Question 6
A nurse is caring for an older adult client who is prescribed multiple
medications. Which of the following physiological changes should the nurse
recognize as a factor that increases the risk of medication toxicity in older
adults?
A) Increased gastric motility
B) Increased hepatic blood flow
C) Decreased renal function
D) Increased lean body mass
E) Increased serum albumin levels
Correct Answer: C) Decreased renal function
Rationale: Aging often leads to decreased renal function (reduced
glomerular filtration rate), which impairs the kidneys' ability to
excrete medications. This can lead to drug accumulation and
increased risk of toxicity. Other changes like decreased hepatic
blood flow and decreased lean body mass also contribute to altered
drug pharmacokinetics in older adults.
Question 7
A nurse is assessing a 4-year-old child at a well-child visit. Which of the
following developmental milestones should the nurse expect to observe?
A) Ties shoelaces independently.
B) Rides a tricycle.
C) Copies a square.
D) Prints own name.
E) Counts to 20.
Correct Answer: B) Rides a tricycle.
Rationale: By 4 years old, children typically have the gross motor
skills to ride a tricycle. Copying a square (around 4-5 years) is a fine
motor skill that might be developing. Tying shoelaces and printing
their name are generally later milestones (5-6+ years), as is
counting to 20 (often 5+ years).
Question 8
A nurse is preparing to administer an opioid analgesic to a client. Which of
, the following assessments should the nurse perform first?
A) Blood pressure
B) Pain level
C) Respiratory rate
D) Level of consciousness
E) Bowel sounds
Correct Answer: C) Respiratory rate
Rationale: Opioid analgesics can cause respiratory depression. The
nurse's priority assessment before administering an opioid is to
check the client's respiratory rate, as a dangerously low rate (e.g.,
<12 breaths/min) may contraindicate or require dose adjustment of
the medication.
Question 9
A nurse is caring for a client who is postoperative and has a new prescription
for a clear liquid diet. Which of the following foods should the nurse offer?
A) Cream of mushroom soup
B) Applesauce
C) Sherbet
D) Gelatin
E) Milk
Correct Answer: D) Gelatin
Rationale: A clear liquid diet consists of foods that are transparent
and liquid at room temperature. Gelatin is a clear liquid. Cream
soups, applesauce, sherbet, and milk are not clear liquids.
Question 10
A nurse is providing teaching to a client who has a new colostomy. Which of
the following statements should the nurse include in the teaching?
A) "Change the ostomy appliance daily."
B) "Empty the ostomy bag when it is half full."
C) "You should expect the stoma to be pale and dry."
D) "Cut the skin barrier opening 1/2 inch larger than the stoma."
E) "It is normal to experience some leakage around the stoma."
Correct Answer: B) "Empty the ostomy bag when it is half full."
Rationale: The ostomy bag should be emptied when it is 1/3 to 1/2 full
to prevent leakage and avoid excessive weight pulling on the
appliance. The stoma should be moist and pink/red. The skin barrier
should be cut precisely to fit the stoma, leaving only 1/8 inch around
the stoma to protect the skin. Leakage is not normal and indicates
an issue with the appliance or skin barrier.
