ATI Comprehensive Practice B 2025 | RN ATI capstone
proctored comprehensive assessment 2025 B | Exam
Questions and Answers | Already Verified Answers
Question 1
A nurse is caring for a client who is 2 days postoperative following a total
knee arthroplasty. The client reports a pain level of 8 on a 0-10 scale and has
a temperature of 38.6°C (101.5°F). The nurse assesses the surgical site and
notes redness and warmth with a moderate amount of serosanguineous
drainage. Which of the following actions should the nurse take first?
A) Administer a prescribed oral antibiotic.
B) Obtain an order for a wound culture.
C) Administer a prescribed opioid analgesic.
D) Notify the provider of the findings.
E) Apply a cool compress to the knee.
Correct Answer: D) Notify the provider of the findings.
Rationale: The client's symptoms (fever, increased pain, and signs of
inflammation/potential infection at the surgical site) indicate a
possible postoperative complication requiring immediate medical
evaluation. Notifying the provider is the priority to ensure prompt
diagnosis and intervention.
Question 2
A nurse is providing discharge teaching to a client who has a new
prescription for enoxaparin. Which of the following statements by the client
indicates an understanding of the teaching?
A) "I will inject the medication into the same spot on my arm each time."
B) "I will aspirate for blood return before injecting."
C) "I will rub the injection site vigorously after injecting."
D) "I will pinch an inch of skin on my abdomen and inject at a 90-degree
angle."
E) "I will take this medication with meals to avoid stomach upset."
Correct Answer: D) "I will pinch an inch of skin on my abdomen and
inject at a 90-degree angle."
Rationale: Enoxaparin is a low molecular weight heparin administered
subcutaneously, typically in the abdomen, using a pinch-an-inch
technique at a 90-degree angle (or 45 degrees if very thin). The
injection site should be alternated, and the site should not be
rubbed or aspirated to prevent bruising and hematoma formation.
Question 3
A nurse is caring for a client who has hypervolemia. Which of the following
findings should the nurse expect?
,A) Dry mucous membranes.
B) Increased urine specific gravity.
C) Peripheral edema.
D) Hypotension.
E) Decreased central venous pressure (CVP).
Correct Answer: C) Peripheral edema.
Rationale: Hypervolemia (fluid volume excess) leads to an increase in
intravascular and interstitial fluid, manifesting as peripheral edema
(swelling in extremities), jugular venous distension, crackles in the
lungs, and weight gain. Dry mucous membranes, increased urine
specific gravity, hypotension, and decreased CVP are associated
with hypovolemia.
Question 4
A nurse is assessing a client who has a suspected fractured tibia. Which of
the following findings is the most critical and requires immediate
intervention?
A) Pain rating of 7 on a 0-10 scale.
B) Swelling and ecchymosis around the fracture site.
C) Inability to bear weight on the affected extremity.
D) Numbness and tingling in the foot distal to the fracture.
E) Visible deformity of the leg.
Correct Answer: D) Numbness and tingling in the foot distal to the
fracture.
Rationale: Numbness and tingling (paresthesia) distal to a fracture
are signs of neurovascular compromise, potentially indicating nerve
damage or, more critically, compartment syndrome due to increased
pressure. This is a limb-threatening emergency requiring immediate
assessment and intervention to prevent irreversible tissue damage.
Question 5
A nurse is providing discharge teaching to a client who has heart failure and
a new prescription for carvedilol. Which of the following instructions should
the nurse include?
A) "Report a sudden weight gain of 2 pounds in one day to your provider."
B) "Discontinue this medication immediately if you feel dizzy."
C) "You should expect your pulse rate to increase significantly."
D) "This medication may cause constipation."
E) "Avoid consuming potassium-rich foods."
Correct Answer: A) "Report a sudden weight gain of 2 pounds in one
day to your provider."
,Rationale: Carvedilol is a beta-blocker often used in heart failure. A
sudden weight gain (e.g., 2-3 pounds in 24 hours or 5 pounds in a
week) can indicate fluid retention and worsening heart failure,
which requires prompt notification of the provider. Clients should be
taught not to discontinue beta-blockers abruptly. Dizziness can be a
side effect, but often improves; significant dizziness or syncope
should be reported. Beta-blockers decrease pulse rate.
Question 6
A nurse is teaching a client who has a new diagnosis of type 2 diabetes
mellitus about managing their condition. Which of the following
recommendations should the nurse prioritize?
A) "You will need to take insulin injections daily."
B) "Limit your intake of all carbohydrates to less than 50 grams per day."
C) "Engage in regular physical activity and follow a balanced meal plan."
D) "Avoid checking your blood glucose more than once a week."
E) "Focus only on weight loss, as it will cure your diabetes."
Correct Answer: C) "Engage in regular physical activity and follow a
balanced meal plan."
Rationale: Regular physical activity and a balanced, healthy meal
plan are foundational for managing type 2 diabetes. They improve
insulin sensitivity, help control blood glucose, and can contribute to
weight management. While insulin may eventually be needed, it's
not the initial priority for all type 2 diabetics. Extreme carbohydrate
restriction is generally not recommended, and daily glucose
monitoring is often essential.
Question 7
A nurse is preparing to administer an opioid analgesic to a client who has a
pain level of 9 on a 0-10 scale. The client's respiratory rate is 10 breaths/min.
Which of the following actions should the nurse take?
A) Administer the opioid as prescribed and closely monitor the respiratory
rate.
B) Administer a reduced dose of the opioid.
C) Withhold the opioid and notify the provider.
D) Obtain an order for naloxone to have at the bedside.
E) Encourage the client to take deep breaths before administration.
Correct Answer: C) Withhold the opioid and notify the provider.
Rationale: A respiratory rate of 10 breaths/min is indicative of
respiratory depression, which is a significant adverse effect of
opioid analgesics. Administering an opioid to a client with an
, already depressed respiratory rate could dangerously worsen their
breathing. The nurse's priority is to withhold the medication and
immediately notify the provider for further orders or evaluation.
Question 8
A nurse is caring for a client who has Clostridium difficile (C. diff) infection.
Which of the following infection control precautions should the nurse
implement?
A) Airborne precautions.
B) Droplet precautions.
C) Contact precautions, including washing hands with soap and water.
D) Standard precautions with an N95 respirator.
E) Protective environment.
Correct Answer: C) Contact precautions, including washing hands with
soap and water.
Rationale: C. diff is spread through spores, which are not effectively
killed by alcohol-based hand rubs. Therefore, contact precautions
(gown and gloves upon room entry) and thorough handwashing with
soap and water are mandatory for C. diff isolation to prevent its
transmission.
Question 9
A nurse is assessing a client who has a traumatic brain injury (TBI) and notes
a Glasgow Coma Scale (GCS) score of 7. Which of the following nursing
interventions is the priority?
A) Obtaining a comprehensive neurological assessment.
B) Elevating the head of the bed to 30 degrees.
C) Preparing for endotracheal intubation.
D) Administering a prescribed sedative.
E) Inserting an indwelling urinary catheter.
Correct Answer: C) Preparing for endotracheal intubation.
Rationale: A GCS score of 8 or less indicates a severe TBI and an
inability to protect the airway. Securing the airway with
endotracheal intubation is the immediate priority to ensure
adequate oxygenation and ventilation, which are critical for
preventing secondary brain injury. Other actions are important but
follow airway management.
Question 10
A nurse is providing discharge teaching to a client who has a new permanent
pacemaker. Which of the following statements by the client indicates a need
proctored comprehensive assessment 2025 B | Exam
Questions and Answers | Already Verified Answers
Question 1
A nurse is caring for a client who is 2 days postoperative following a total
knee arthroplasty. The client reports a pain level of 8 on a 0-10 scale and has
a temperature of 38.6°C (101.5°F). The nurse assesses the surgical site and
notes redness and warmth with a moderate amount of serosanguineous
drainage. Which of the following actions should the nurse take first?
A) Administer a prescribed oral antibiotic.
B) Obtain an order for a wound culture.
C) Administer a prescribed opioid analgesic.
D) Notify the provider of the findings.
E) Apply a cool compress to the knee.
Correct Answer: D) Notify the provider of the findings.
Rationale: The client's symptoms (fever, increased pain, and signs of
inflammation/potential infection at the surgical site) indicate a
possible postoperative complication requiring immediate medical
evaluation. Notifying the provider is the priority to ensure prompt
diagnosis and intervention.
Question 2
A nurse is providing discharge teaching to a client who has a new
prescription for enoxaparin. Which of the following statements by the client
indicates an understanding of the teaching?
A) "I will inject the medication into the same spot on my arm each time."
B) "I will aspirate for blood return before injecting."
C) "I will rub the injection site vigorously after injecting."
D) "I will pinch an inch of skin on my abdomen and inject at a 90-degree
angle."
E) "I will take this medication with meals to avoid stomach upset."
Correct Answer: D) "I will pinch an inch of skin on my abdomen and
inject at a 90-degree angle."
Rationale: Enoxaparin is a low molecular weight heparin administered
subcutaneously, typically in the abdomen, using a pinch-an-inch
technique at a 90-degree angle (or 45 degrees if very thin). The
injection site should be alternated, and the site should not be
rubbed or aspirated to prevent bruising and hematoma formation.
Question 3
A nurse is caring for a client who has hypervolemia. Which of the following
findings should the nurse expect?
,A) Dry mucous membranes.
B) Increased urine specific gravity.
C) Peripheral edema.
D) Hypotension.
E) Decreased central venous pressure (CVP).
Correct Answer: C) Peripheral edema.
Rationale: Hypervolemia (fluid volume excess) leads to an increase in
intravascular and interstitial fluid, manifesting as peripheral edema
(swelling in extremities), jugular venous distension, crackles in the
lungs, and weight gain. Dry mucous membranes, increased urine
specific gravity, hypotension, and decreased CVP are associated
with hypovolemia.
Question 4
A nurse is assessing a client who has a suspected fractured tibia. Which of
the following findings is the most critical and requires immediate
intervention?
A) Pain rating of 7 on a 0-10 scale.
B) Swelling and ecchymosis around the fracture site.
C) Inability to bear weight on the affected extremity.
D) Numbness and tingling in the foot distal to the fracture.
E) Visible deformity of the leg.
Correct Answer: D) Numbness and tingling in the foot distal to the
fracture.
Rationale: Numbness and tingling (paresthesia) distal to a fracture
are signs of neurovascular compromise, potentially indicating nerve
damage or, more critically, compartment syndrome due to increased
pressure. This is a limb-threatening emergency requiring immediate
assessment and intervention to prevent irreversible tissue damage.
Question 5
A nurse is providing discharge teaching to a client who has heart failure and
a new prescription for carvedilol. Which of the following instructions should
the nurse include?
A) "Report a sudden weight gain of 2 pounds in one day to your provider."
B) "Discontinue this medication immediately if you feel dizzy."
C) "You should expect your pulse rate to increase significantly."
D) "This medication may cause constipation."
E) "Avoid consuming potassium-rich foods."
Correct Answer: A) "Report a sudden weight gain of 2 pounds in one
day to your provider."
,Rationale: Carvedilol is a beta-blocker often used in heart failure. A
sudden weight gain (e.g., 2-3 pounds in 24 hours or 5 pounds in a
week) can indicate fluid retention and worsening heart failure,
which requires prompt notification of the provider. Clients should be
taught not to discontinue beta-blockers abruptly. Dizziness can be a
side effect, but often improves; significant dizziness or syncope
should be reported. Beta-blockers decrease pulse rate.
Question 6
A nurse is teaching a client who has a new diagnosis of type 2 diabetes
mellitus about managing their condition. Which of the following
recommendations should the nurse prioritize?
A) "You will need to take insulin injections daily."
B) "Limit your intake of all carbohydrates to less than 50 grams per day."
C) "Engage in regular physical activity and follow a balanced meal plan."
D) "Avoid checking your blood glucose more than once a week."
E) "Focus only on weight loss, as it will cure your diabetes."
Correct Answer: C) "Engage in regular physical activity and follow a
balanced meal plan."
Rationale: Regular physical activity and a balanced, healthy meal
plan are foundational for managing type 2 diabetes. They improve
insulin sensitivity, help control blood glucose, and can contribute to
weight management. While insulin may eventually be needed, it's
not the initial priority for all type 2 diabetics. Extreme carbohydrate
restriction is generally not recommended, and daily glucose
monitoring is often essential.
Question 7
A nurse is preparing to administer an opioid analgesic to a client who has a
pain level of 9 on a 0-10 scale. The client's respiratory rate is 10 breaths/min.
Which of the following actions should the nurse take?
A) Administer the opioid as prescribed and closely monitor the respiratory
rate.
B) Administer a reduced dose of the opioid.
C) Withhold the opioid and notify the provider.
D) Obtain an order for naloxone to have at the bedside.
E) Encourage the client to take deep breaths before administration.
Correct Answer: C) Withhold the opioid and notify the provider.
Rationale: A respiratory rate of 10 breaths/min is indicative of
respiratory depression, which is a significant adverse effect of
opioid analgesics. Administering an opioid to a client with an
, already depressed respiratory rate could dangerously worsen their
breathing. The nurse's priority is to withhold the medication and
immediately notify the provider for further orders or evaluation.
Question 8
A nurse is caring for a client who has Clostridium difficile (C. diff) infection.
Which of the following infection control precautions should the nurse
implement?
A) Airborne precautions.
B) Droplet precautions.
C) Contact precautions, including washing hands with soap and water.
D) Standard precautions with an N95 respirator.
E) Protective environment.
Correct Answer: C) Contact precautions, including washing hands with
soap and water.
Rationale: C. diff is spread through spores, which are not effectively
killed by alcohol-based hand rubs. Therefore, contact precautions
(gown and gloves upon room entry) and thorough handwashing with
soap and water are mandatory for C. diff isolation to prevent its
transmission.
Question 9
A nurse is assessing a client who has a traumatic brain injury (TBI) and notes
a Glasgow Coma Scale (GCS) score of 7. Which of the following nursing
interventions is the priority?
A) Obtaining a comprehensive neurological assessment.
B) Elevating the head of the bed to 30 degrees.
C) Preparing for endotracheal intubation.
D) Administering a prescribed sedative.
E) Inserting an indwelling urinary catheter.
Correct Answer: C) Preparing for endotracheal intubation.
Rationale: A GCS score of 8 or less indicates a severe TBI and an
inability to protect the airway. Securing the airway with
endotracheal intubation is the immediate priority to ensure
adequate oxygenation and ventilation, which are critical for
preventing secondary brain injury. Other actions are important but
follow airway management.
Question 10
A nurse is providing discharge teaching to a client who has a new permanent
pacemaker. Which of the following statements by the client indicates a need
