RN ATI CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT FORM A & B: 357 QUESTIONS
WITH 100% CORRECT ANSWERS & DETAILED
RATIONALES
Question 1
The emergency department triage nurse receives notification of a mass shooting
incident at a local shopping mall with several casualties. The hospital’s emergency
response plan is initiated. Which client should the nurse prioritize for care?
A. Client with a sucking chest wound, conscious, BP 88/58 mm Hg, HR 115/min,
red tag.
B. Client with penetrating head wound, unconscious, irregular breathing, black
tag.
C. Client with superficial lacerations to left arm and left lower leg.
D. Client with closed left lower leg injury, air cast in place, pain 9/10.
Correct Answer: A
A sucking chest wound compromises breathing, can cause tension pneumothorax,
and decreases cardiac output. Hypotension and tachycardia indicate shock. Red
tag means life-threatening but survivable – needs immediate intervention.
Question 2
The nurse should identify that Client 1 requires priority care due to which reason?
,A. Severe but survivable injuries.
B. Minor injuries requiring immediate care.
C. Non-life-threatening injuries requiring follow-up.
D. Injuries that do not need urgent attention.
Correct Answer: A
Severe but survivable injuries demand immediate stabilization of airway,
breathing, and circulation. Red tag cases require prompt intervention for better
survival outcomes.
Question 3
Which client should receive immediate intervention?
A. Sucking chest wound, conscious, BP 88/58, HR 115, red tag.
B. Penetrating head wound, unconscious, irregular breathing, black tag.
C. Superficial lacerations, occlusive dressing, tearful, BP 118/78, green tag.
D. Closed lower leg injury, air cast, pain 9/10, yellow tag.
Correct Answer: A
Sucking chest wound impairs oxygenation and causes shock. Red tag = life-
threatening but treatable – needs priority.
Question 4
Which prescription should the nurse clarify with the provider prior to
administration?
A. Potassium chloride 20 mEq PO daily.
B. HCTZ 25 mg PO daily.
C. Amlodipine 10 mg PO daily.
D. Clonidine 1 mg PO TID PRN for SBP >180.
Correct Answer: D
Clonidine 1 mg TID is excessive (normal 0.1-0.3 mg). High dose risks severe
hypotension, bradycardia, withdrawal.
,Question 5
A nurse is caring for a client in the ED. Which action should the nurse take based
on the MAR at 1130?
A. Administer albuterol nebulizer 2.5 mg at 1130.
B. Administer methylprednisolone 50 mg at 1130.
C. Reassess vital signs before administering medications.
D. Notify provider if symptoms worsen after administration.
Correct Answer: C
Reassessing vital signs ensures patient stability before med administration,
especially in emergencies to prevent deterioration.
Question 6
Based on physical exam findings, which assessment indicates the client’s condition
is worsening?
A. Cyanotic mucous membranes, O2 sat 84% on 3L NC.
B. Diffuse wheezing and hand tremor.
C. BP 168/90, HR 98.
D. Clear rhinorrhea, skin warm/dry.
Correct Answer: A
Cyanosis and O2 sat 84% indicate severe hypoxemia (normal 95-100%), requiring
immediate intervention to prevent respiratory failure.
Question 7
A nurse on a medical-surgical unit should prioritize which intervention?
A. Monitoring BP trends after antihypertensives.
B. Administering potassium chloride 20 mEq PO STAT.
, C. Reassessing for med needs at 1300.
D. Teaching about stable BP.
Correct Answer: B
Potassium chloride STAT addresses potential hypokalemia (normal 3.5-5.0), which
risks arrhythmias and weakness – urgent.
Question 8
A nurse is assessing a client with heart failure. Which finding requires immediate
intervention?
A. +2 pitting edema in lower extremities.
B. Crackles bilaterally in lung bases.
C. Oxygen saturation 89% on room air.
D. Weight gain of 1 lb in 24 hours.
Correct Answer: C
O2 sat 89% indicates hypoxemia, risking organ damage. Needs oxygen therapy
immediately.
Question 9
A client with diabetes mellitus type 1 has a blood glucose of 45 mg/dL and is
unconscious. What should the nurse do first?
A. Give 15 g of oral glucose.
B. Administer glucagon IM.
C. Start IV dextrose 50% push.
D. Recheck glucose in 15 minutes.
Correct Answer: B
Unconscious client cannot swallow. Glucagon IM raises glucose rapidly. IV
dextrose is second-line if no response or IV available.
ASSESSMENT FORM A & B: 357 QUESTIONS
WITH 100% CORRECT ANSWERS & DETAILED
RATIONALES
Question 1
The emergency department triage nurse receives notification of a mass shooting
incident at a local shopping mall with several casualties. The hospital’s emergency
response plan is initiated. Which client should the nurse prioritize for care?
A. Client with a sucking chest wound, conscious, BP 88/58 mm Hg, HR 115/min,
red tag.
B. Client with penetrating head wound, unconscious, irregular breathing, black
tag.
C. Client with superficial lacerations to left arm and left lower leg.
D. Client with closed left lower leg injury, air cast in place, pain 9/10.
Correct Answer: A
A sucking chest wound compromises breathing, can cause tension pneumothorax,
and decreases cardiac output. Hypotension and tachycardia indicate shock. Red
tag means life-threatening but survivable – needs immediate intervention.
Question 2
The nurse should identify that Client 1 requires priority care due to which reason?
,A. Severe but survivable injuries.
B. Minor injuries requiring immediate care.
C. Non-life-threatening injuries requiring follow-up.
D. Injuries that do not need urgent attention.
Correct Answer: A
Severe but survivable injuries demand immediate stabilization of airway,
breathing, and circulation. Red tag cases require prompt intervention for better
survival outcomes.
Question 3
Which client should receive immediate intervention?
A. Sucking chest wound, conscious, BP 88/58, HR 115, red tag.
B. Penetrating head wound, unconscious, irregular breathing, black tag.
C. Superficial lacerations, occlusive dressing, tearful, BP 118/78, green tag.
D. Closed lower leg injury, air cast, pain 9/10, yellow tag.
Correct Answer: A
Sucking chest wound impairs oxygenation and causes shock. Red tag = life-
threatening but treatable – needs priority.
Question 4
Which prescription should the nurse clarify with the provider prior to
administration?
A. Potassium chloride 20 mEq PO daily.
B. HCTZ 25 mg PO daily.
C. Amlodipine 10 mg PO daily.
D. Clonidine 1 mg PO TID PRN for SBP >180.
Correct Answer: D
Clonidine 1 mg TID is excessive (normal 0.1-0.3 mg). High dose risks severe
hypotension, bradycardia, withdrawal.
,Question 5
A nurse is caring for a client in the ED. Which action should the nurse take based
on the MAR at 1130?
A. Administer albuterol nebulizer 2.5 mg at 1130.
B. Administer methylprednisolone 50 mg at 1130.
C. Reassess vital signs before administering medications.
D. Notify provider if symptoms worsen after administration.
Correct Answer: C
Reassessing vital signs ensures patient stability before med administration,
especially in emergencies to prevent deterioration.
Question 6
Based on physical exam findings, which assessment indicates the client’s condition
is worsening?
A. Cyanotic mucous membranes, O2 sat 84% on 3L NC.
B. Diffuse wheezing and hand tremor.
C. BP 168/90, HR 98.
D. Clear rhinorrhea, skin warm/dry.
Correct Answer: A
Cyanosis and O2 sat 84% indicate severe hypoxemia (normal 95-100%), requiring
immediate intervention to prevent respiratory failure.
Question 7
A nurse on a medical-surgical unit should prioritize which intervention?
A. Monitoring BP trends after antihypertensives.
B. Administering potassium chloride 20 mEq PO STAT.
, C. Reassessing for med needs at 1300.
D. Teaching about stable BP.
Correct Answer: B
Potassium chloride STAT addresses potential hypokalemia (normal 3.5-5.0), which
risks arrhythmias and weakness – urgent.
Question 8
A nurse is assessing a client with heart failure. Which finding requires immediate
intervention?
A. +2 pitting edema in lower extremities.
B. Crackles bilaterally in lung bases.
C. Oxygen saturation 89% on room air.
D. Weight gain of 1 lb in 24 hours.
Correct Answer: C
O2 sat 89% indicates hypoxemia, risking organ damage. Needs oxygen therapy
immediately.
Question 9
A client with diabetes mellitus type 1 has a blood glucose of 45 mg/dL and is
unconscious. What should the nurse do first?
A. Give 15 g of oral glucose.
B. Administer glucagon IM.
C. Start IV dextrose 50% push.
D. Recheck glucose in 15 minutes.
Correct Answer: B
Unconscious client cannot swallow. Glucagon IM raises glucose rapidly. IV
dextrose is second-line if no response or IV available.
