RN ATI CAPSTONE COMPREHENSIVE ASSESSMENT B COMPLETE ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS/ GRADE A+ ASSURED(REAL
DEAL)
Question 1
A nurse is providing discharge teaching to the parents of a newborn about umbilical cord care.
Which of the following instructions should the nurse include?
A) Apply a topical antibiotic ointment to the cord daily.
B) Keep the cord stump dry and exposed to air.
C) Cover the cord with the top of the diaper to keep it clean.
D) Cleanse the cord with alcohol at each diaper change.
Correct Answer: B) Keep the cord stump dry and exposed to air.
Rationale: Current evidence-based practice recommends keeping the umbilical cord stump
clean and dry to promote separation and prevent infection. Folding the diaper down below
the cord allows for air circulation.
Question 2
A nurse is admitting a client who has a terminal illness. The client states, "I have a living will and
a durable power of attorney for healthcare." The nurse's action should be based on which of the
following ethical principles?
A) The Patient Self-Determination Act (PSDA)
B) Veracity
C) Beneficence
D) Fidelity
Correct Answer: A) The Patient Self-Determination Act (PSDA)
Rationale: The PSDA is a federal law that requires healthcare facilities to ask clients about
advance directives upon admission and to provide information about their right to make
healthcare decisions. The nurse's responsibility is to document the existence of these
directives.
Question 3
A client in a rural area is having difficulty managing their diabetes. Which of the following
services would be most beneficial for providing ongoing management and education?
,A) In-home nursing visits
B) Telehealth services
C) A monthly clinic appointment
D) A referral to a local support group
Correct Answer: B) Telehealth services
Rationale: Telehealth utilizes technology to provide remote healthcare consultations,
monitoring, and education. It is particularly effective for clients in rural areas with limited
access to specialists, allowing for more frequent and convenient management of chronic
conditions like diabetes.
Question 4
A nurse is providing dietary teaching for a client who has type 2 diabetes mellitus. Which of the
following food choices is the best recommendation?
A) A baked potato with sour cream.
B) White rice with steamed vegetables.
C) A corn tortilla with black beans.
D) A glass of orange juice.
Correct Answer: C) A corn tortilla with black beans.
Rationale: This option provides a good source of complex carbohydrates and fiber from the
corn and black beans. Fiber helps to slow the absorption of glucose, promoting better blood
sugar control compared to the simple or refined carbohydrates in the other options.
Question 5
A nurse is teaching the parent of a preschooler who has celiac disease. Which of the following
foods should the nurse recommend including in the child's diet?
A) Wheat toast
B) Oatmeal
C) Rice cereal
D) Rye crackers
Correct Answer: C) Rice cereal
Rationale: Celiac disease is an autoimmune disorder where the ingestion of gluten leads to
,damage in the small intestine. Rice is a naturally gluten-free grain and is a safe choice. Wheat,
rye, and most oats (due to cross-contamination) contain gluten and must be avoided.
Question 6
A nurse is assessing a client for orthostatic hypotension. Which of the following findings
indicates a positive result?
A) A drop in systolic BP of 25 mm Hg when moving from lying to sitting.
B) An increase in heart rate of 10 beats/min upon standing.
C) A drop in diastolic BP of 5 mm Hg when standing.
D) An unchanged systolic BP with a change in position.
Correct Answer: A) A drop in systolic BP of 25 mm Hg when moving from lying to sitting.
Rationale: Orthostatic hypotension is generally defined as a drop in systolic blood pressure of
20 mm Hg or more, or a drop in diastolic blood pressure of 10 mm Hg or more, within three
minutes of standing. A 25 mm Hg drop is a significant positive finding.
Question 7
A nurse is caring for a client who is on mechanical ventilation. The high-pressure alarm sounds.
What is the most likely cause?
A) A disconnection in the ventilator tubing.
B) The client is extubating themself.
C) An airway obstruction.
D) A leak in the endotracheal tube cuff.
Correct Answer: C) An airway obstruction.
Rationale: A high-pressure alarm indicates that the ventilator is meeting increased resistance
when trying to deliver a breath. This can be caused by the client coughing, biting the tube, or
having an obstruction from secretions (mucus plug). Low-pressure alarms are caused by
disconnections or leaks.
Question 8
A nurse is planning meals for a client who had a stroke and has dysphagia. Which of the
following food items is the most appropriate choice?
, A) A piece of toast
B) Scrambled eggs
C) A tossed salad
D) A cup of thin broth
Correct Answer: B) Scrambled eggs
Rationale: Clients with dysphagia (difficulty swallowing) require foods with a soft, consistent
texture to reduce the risk of aspiration. Scrambled eggs are soft and easy to chew and
swallow. Thin liquids, toast, and salads are all high-risk for aspiration.
Question 9
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening
the sterile kit and donning sterile gloves, which of the following is the next step?
A) Cleanse the urinary meatus.
B) Lubricate the catheter tip.
C) Position the sterile drape to expose the perineum.
D) Inflate and test the catheter balloon.
Correct Answer: C) Position the sterile drape to expose the perineum.
Rationale: After establishing a sterile field and donning sterile gloves, the next step is to place
the sterile drapes. The fenestrated (holed) drape is placed over the perineum to create a
larger sterile working area before cleansing or handling the catheter.
Question 10
A nurse is monitoring a client who is receiving a blood transfusion. The client develops chills,
flushing, and chest tightness. The nurse should suspect which type of transfusion reaction?
A) Allergic reaction
B) Febrile non-hemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Correct Answer: C) Acute hemolytic reaction
Rationale: An acute hemolytic reaction is a life-threatening reaction caused by an ABO
QUESTIONS AND CORRECT DETAILED ANSWERS/ GRADE A+ ASSURED(REAL
DEAL)
Question 1
A nurse is providing discharge teaching to the parents of a newborn about umbilical cord care.
Which of the following instructions should the nurse include?
A) Apply a topical antibiotic ointment to the cord daily.
B) Keep the cord stump dry and exposed to air.
C) Cover the cord with the top of the diaper to keep it clean.
D) Cleanse the cord with alcohol at each diaper change.
Correct Answer: B) Keep the cord stump dry and exposed to air.
Rationale: Current evidence-based practice recommends keeping the umbilical cord stump
clean and dry to promote separation and prevent infection. Folding the diaper down below
the cord allows for air circulation.
Question 2
A nurse is admitting a client who has a terminal illness. The client states, "I have a living will and
a durable power of attorney for healthcare." The nurse's action should be based on which of the
following ethical principles?
A) The Patient Self-Determination Act (PSDA)
B) Veracity
C) Beneficence
D) Fidelity
Correct Answer: A) The Patient Self-Determination Act (PSDA)
Rationale: The PSDA is a federal law that requires healthcare facilities to ask clients about
advance directives upon admission and to provide information about their right to make
healthcare decisions. The nurse's responsibility is to document the existence of these
directives.
Question 3
A client in a rural area is having difficulty managing their diabetes. Which of the following
services would be most beneficial for providing ongoing management and education?
,A) In-home nursing visits
B) Telehealth services
C) A monthly clinic appointment
D) A referral to a local support group
Correct Answer: B) Telehealth services
Rationale: Telehealth utilizes technology to provide remote healthcare consultations,
monitoring, and education. It is particularly effective for clients in rural areas with limited
access to specialists, allowing for more frequent and convenient management of chronic
conditions like diabetes.
Question 4
A nurse is providing dietary teaching for a client who has type 2 diabetes mellitus. Which of the
following food choices is the best recommendation?
A) A baked potato with sour cream.
B) White rice with steamed vegetables.
C) A corn tortilla with black beans.
D) A glass of orange juice.
Correct Answer: C) A corn tortilla with black beans.
Rationale: This option provides a good source of complex carbohydrates and fiber from the
corn and black beans. Fiber helps to slow the absorption of glucose, promoting better blood
sugar control compared to the simple or refined carbohydrates in the other options.
Question 5
A nurse is teaching the parent of a preschooler who has celiac disease. Which of the following
foods should the nurse recommend including in the child's diet?
A) Wheat toast
B) Oatmeal
C) Rice cereal
D) Rye crackers
Correct Answer: C) Rice cereal
Rationale: Celiac disease is an autoimmune disorder where the ingestion of gluten leads to
,damage in the small intestine. Rice is a naturally gluten-free grain and is a safe choice. Wheat,
rye, and most oats (due to cross-contamination) contain gluten and must be avoided.
Question 6
A nurse is assessing a client for orthostatic hypotension. Which of the following findings
indicates a positive result?
A) A drop in systolic BP of 25 mm Hg when moving from lying to sitting.
B) An increase in heart rate of 10 beats/min upon standing.
C) A drop in diastolic BP of 5 mm Hg when standing.
D) An unchanged systolic BP with a change in position.
Correct Answer: A) A drop in systolic BP of 25 mm Hg when moving from lying to sitting.
Rationale: Orthostatic hypotension is generally defined as a drop in systolic blood pressure of
20 mm Hg or more, or a drop in diastolic blood pressure of 10 mm Hg or more, within three
minutes of standing. A 25 mm Hg drop is a significant positive finding.
Question 7
A nurse is caring for a client who is on mechanical ventilation. The high-pressure alarm sounds.
What is the most likely cause?
A) A disconnection in the ventilator tubing.
B) The client is extubating themself.
C) An airway obstruction.
D) A leak in the endotracheal tube cuff.
Correct Answer: C) An airway obstruction.
Rationale: A high-pressure alarm indicates that the ventilator is meeting increased resistance
when trying to deliver a breath. This can be caused by the client coughing, biting the tube, or
having an obstruction from secretions (mucus plug). Low-pressure alarms are caused by
disconnections or leaks.
Question 8
A nurse is planning meals for a client who had a stroke and has dysphagia. Which of the
following food items is the most appropriate choice?
, A) A piece of toast
B) Scrambled eggs
C) A tossed salad
D) A cup of thin broth
Correct Answer: B) Scrambled eggs
Rationale: Clients with dysphagia (difficulty swallowing) require foods with a soft, consistent
texture to reduce the risk of aspiration. Scrambled eggs are soft and easy to chew and
swallow. Thin liquids, toast, and salads are all high-risk for aspiration.
Question 9
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening
the sterile kit and donning sterile gloves, which of the following is the next step?
A) Cleanse the urinary meatus.
B) Lubricate the catheter tip.
C) Position the sterile drape to expose the perineum.
D) Inflate and test the catheter balloon.
Correct Answer: C) Position the sterile drape to expose the perineum.
Rationale: After establishing a sterile field and donning sterile gloves, the next step is to place
the sterile drapes. The fenestrated (holed) drape is placed over the perineum to create a
larger sterile working area before cleansing or handling the catheter.
Question 10
A nurse is monitoring a client who is receiving a blood transfusion. The client develops chills,
flushing, and chest tightness. The nurse should suspect which type of transfusion reaction?
A) Allergic reaction
B) Febrile non-hemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Correct Answer: C) Acute hemolytic reaction
Rationale: An acute hemolytic reaction is a life-threatening reaction caused by an ABO
