ATI Fundamentals CMS Proctored
Exam
210 Questions and Verified Answers
2026 | 2027 Latest Edition | 100% Correct
Aligned with NCLEX-RN Test Plan Standards
Comprehensive Nursing Fundamentals Application
Table of Contents
Section 1: Safe, Effective Care Environment — Q1–Q40
Section 2: Safety and Infection Control — Q41–Q75
Section 3: Health Promotion and Maintenance — Q76–Q105
Section 4: Psychosocial Integrity — Q106–Q135
Section 5: Basic Care and Comfort — Q136–Q170
Section 6: Pharmacological and Parenteral Therapies — Q171–Q190
Section 7: Reduction of Risk Potential — Q191–Q200
Section 8: Physiological Adaptation — Q201–Q210
,Section 1: Safe, Effective Care Environment
Q1: A nurse is caring for a client who is scheduled for a colonoscopy. The client signed
the informed consent form earlier in the day but now tells the nurse, 'I changed my
mind. I don't want this procedure done.' Which of the following actions should the
nurse take?
A. Tell the client the procedure is already scheduled and cannot be canceled.
B. Notify the provider immediately and document the client's refusal. [CORRECT]
C. Explain the risks of not having the procedure and encourage the client to reconsider.
D. Ask the client's family to persuade the client to go through with the procedure.
Correct Answer: B
Rationale: The client has the right to refuse any treatment or procedure at any time, even after signing a consent
form. The nurse must notify the provider and document the refusal. The nurse should not coerce the client or
involve family to override the client's decision, as this violates client autonomy.
Q2: A nurse is preparing to delegate tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate to the AP?
A. Performing a sterile dressing change on a surgical wound.
B. Measuring and recording a client's intake and output. [CORRECT]
C. Evaluating a client's response to a newly administered medication.
D. Assessing a client's respiratory status after a chest tube insertion.
Correct Answer: B
Rationale: Measuring and recording intake and output is within the scope of an AP and does not require nursing
judgment. Sterile dressing changes, medication evaluation, and respiratory assessment require nursing education
and clinical judgment and must be performed by the nurse (RN or LPN depending on scope).
Q3: A nurse witnesses a client sign an informed consent form for a cholecystectomy.
The client asks the nurse, 'What are the risks of this surgery?' Which of the following
is the appropriate response by the nurse?
A. Tell the client the risks include bleeding and infection.
B. Refer the client to the surgeon for explanation of risks and potential complications.
[CORRECT]
C. Read the consent form to the client so they understand the risks.
D. Document that the client asked about risks and continue with preoperative preparation.
Correct Answer: B
Rationale: The provider (surgeon) is responsible for explaining the procedure, risks, benefits, and alternatives to
the client. The nurse's role is to witness the client's signature and ensure the client appears to understand and has
not been coerced. The nurse should not interpret or explain the procedure risks, as this is outside the nurse's legal
scope for informed consent.
Q4: A nurse on a medical-surgical unit receives report on four clients. Which of the
following tasks should the nurse delegate to the LPN?
A. Admitting a new client with a history of seizures and completing the initial assessment.
B. Administering an oral analgesic to a client with chronic pain. [CORRECT]
C. Developing a nursing care plan for a client newly diagnosed with diabetes.
D. Teaching a client how to perform self-catheterization.
Correct Answer: B
1
,Rationale: Administering oral medications is within the scope of an LPN. The RN is responsible for initial
assessments, developing care plans, and client education, as these require the advanced assessment skills and
clinical judgment unique to RN practice. Delegating these tasks to an LPN would exceed the LPN's scope.
Q5: A nurse is caring for a client who has an advance directive stating 'Do Not
Resuscitate' (DNR). The client's family members insist that the nurse perform CPR if
the client's heart stops. Which of the following actions should the nurse take?
A. Follow the family's wishes because they are the client's next of kin.
B. Perform CPR until the provider can be reached for clarification.
C. Honor the client's advance directive and do not initiate CPR. [CORRECT]
D. Call the hospital ethics committee before taking any action.
Correct Answer: C
Rationale: An advance directive is a legally binding document that reflects the client's autonomous wishes. The
nurse must honor the DNR order and should not initiate CPR. Family members cannot override a competent client's
advance directive. The nurse should support the family emotionally but uphold the client's documented wishes.
Q6: Which of the following situations constitutes an example of negligence?
A. A nurse administers a medication as prescribed, and the client develops an unexpected allergic
reaction.
B. A nurse fails to check a client's blood glucose level before administering insulin,
resulting in hypoglycemia. [CORRECT]
C. A nurse discusses a client's diagnosis with the client's spouse who is present during the visit.
D. A nurse delegates vital signs to an AP and the AP reports an elevated temperature to the
nurse.
Correct Answer: B
Rationale: Negligence requires four elements: duty, breach of duty, causation, and damages. The nurse had a
duty to check blood glucose before administering insulin, breached that duty by failing to do so, directly caused
the hypoglycemia, and the client suffered harm (damages). An unexpected allergic reaction to a correctly
administered medication is not negligence, and sharing information with a spouse present during the visit is
generally permitted.
Q7: A nurse is caring for a client who is placed in soft wrist restraints. Which of the
following actions by the nurse is appropriate?
A. Tie the restraints to the side rails of the bed for security.
B. Remove the restraints every 2 hours to assess skin integrity and circulation for an adult client.
C. Obtain a renewal of the restraint order every 4 hours for an adult client. [CORRECT]
D. Apply the restraints tightly to prevent the client from pulling at the IV line.
Correct Answer: C
Rationale: For adult clients, a restraint order must be renewed every 4 hours. Restraints should be tied to a
movable portion of the bed frame (not side rails), removed and range of motion performed at least every 2 hours,
and secured loosely enough to allow two fingers to slip underneath. Monitoring neurovascular status should occur
every 15 to 30 minutes.
Q8: A nurse receives a telephone call from a person who identifies himself as a client's
employer and requests information about the client's diagnosis and expected return
date. Which of the following responses should the nurse make?
A. Provide the information since the employer may have a legitimate need to know.
B. Verify the caller's identity and then provide the information.
2
, C. Inform the caller that client information cannot be disclosed without the client's
written authorization. [CORRECT]
D. Transfer the call to the client's room so the employer can ask the client directly.
Correct Answer: C
Rationale: HIPAA prohibits disclosure of protected health information (PHI) to anyone without the client's written
authorization. The nurse must not provide any information about the client's diagnosis, condition, or expected
discharge to the employer. Even verifying identity is insufficient; written authorization from the client is required
before any PHI can be shared.
Q9: A nurse delegates a task to an assistive personnel. Which of the following is the
most important component of the right direction and communication?
A. Providing the AP with a written list of all tasks for the shift.
B. Telling the AP to report any abnormal findings to the nurse immediately. [CORRECT]
C. Asking the AP to follow the same routine used on the previous shift.
D. Documenting in the chart that the task was delegated to the AP.
Correct Answer: B
Rationale: The right direction and communication includes providing clear instructions, including what to do, how
to do it, and what to report back to the nurse. The most critical element is telling the AP what findings to report
back immediately so the nurse can intervene appropriately. This ensures safe, timely client care and is a core
component of the Five Rights of Delegation.
Q10: A nurse is caring for a 7-year-old child who has been placed in restraints. How
often should the nurse obtain a renewal of the restraint order for this client?
A. Every 1 hour. [CORRECT]
B. Every 2 hours.
C. Every 4 hours.
D. Every 8 hours.
Correct Answer: A
Rationale: For children under 9 years of age, a restraint order must be renewed every 1 hour. For adolescents
aged 9 to 17 years, renewal is required every 2 hours. For adults (18 years and older), the renewal period is every
4 hours. These CMS/Joint Commission requirements ensure frequent reassessment of the continued need for
restraints in younger clients.
Q11: A nurse observes a colleague arriving for the night shift appearing intoxicated
and smelling of alcohol. Which of the following actions should the nurse take first?
A. Confront the colleague and ask them to go home.
B. Report the observation to the nursing supervisor immediately. [CORRECT]
C. Allow the colleague to work but assign them only non-critical tasks.
D. Document the observation in the colleague's personnel file.
Correct Answer: B
Rationale: The nurse has a mandatory reporting obligation regarding impaired colleagues. The first action is to
report the observation to the nursing supervisor immediately to protect client safety. The supervisor is responsible
for further investigation and action. The nurse should not confront the colleague alone, allow them to work in any
capacity, or document in a personnel file, as these are not the appropriate channels.
Q12: A client who is 17 years old is admitted to the hospital for treatment of a
fractured femur. The client's parents are not available, and the surgeon needs to
perform emergency surgery. In this situation, which of the following is true regarding
informed consent?
3
Exam
210 Questions and Verified Answers
2026 | 2027 Latest Edition | 100% Correct
Aligned with NCLEX-RN Test Plan Standards
Comprehensive Nursing Fundamentals Application
Table of Contents
Section 1: Safe, Effective Care Environment — Q1–Q40
Section 2: Safety and Infection Control — Q41–Q75
Section 3: Health Promotion and Maintenance — Q76–Q105
Section 4: Psychosocial Integrity — Q106–Q135
Section 5: Basic Care and Comfort — Q136–Q170
Section 6: Pharmacological and Parenteral Therapies — Q171–Q190
Section 7: Reduction of Risk Potential — Q191–Q200
Section 8: Physiological Adaptation — Q201–Q210
,Section 1: Safe, Effective Care Environment
Q1: A nurse is caring for a client who is scheduled for a colonoscopy. The client signed
the informed consent form earlier in the day but now tells the nurse, 'I changed my
mind. I don't want this procedure done.' Which of the following actions should the
nurse take?
A. Tell the client the procedure is already scheduled and cannot be canceled.
B. Notify the provider immediately and document the client's refusal. [CORRECT]
C. Explain the risks of not having the procedure and encourage the client to reconsider.
D. Ask the client's family to persuade the client to go through with the procedure.
Correct Answer: B
Rationale: The client has the right to refuse any treatment or procedure at any time, even after signing a consent
form. The nurse must notify the provider and document the refusal. The nurse should not coerce the client or
involve family to override the client's decision, as this violates client autonomy.
Q2: A nurse is preparing to delegate tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate to the AP?
A. Performing a sterile dressing change on a surgical wound.
B. Measuring and recording a client's intake and output. [CORRECT]
C. Evaluating a client's response to a newly administered medication.
D. Assessing a client's respiratory status after a chest tube insertion.
Correct Answer: B
Rationale: Measuring and recording intake and output is within the scope of an AP and does not require nursing
judgment. Sterile dressing changes, medication evaluation, and respiratory assessment require nursing education
and clinical judgment and must be performed by the nurse (RN or LPN depending on scope).
Q3: A nurse witnesses a client sign an informed consent form for a cholecystectomy.
The client asks the nurse, 'What are the risks of this surgery?' Which of the following
is the appropriate response by the nurse?
A. Tell the client the risks include bleeding and infection.
B. Refer the client to the surgeon for explanation of risks and potential complications.
[CORRECT]
C. Read the consent form to the client so they understand the risks.
D. Document that the client asked about risks and continue with preoperative preparation.
Correct Answer: B
Rationale: The provider (surgeon) is responsible for explaining the procedure, risks, benefits, and alternatives to
the client. The nurse's role is to witness the client's signature and ensure the client appears to understand and has
not been coerced. The nurse should not interpret or explain the procedure risks, as this is outside the nurse's legal
scope for informed consent.
Q4: A nurse on a medical-surgical unit receives report on four clients. Which of the
following tasks should the nurse delegate to the LPN?
A. Admitting a new client with a history of seizures and completing the initial assessment.
B. Administering an oral analgesic to a client with chronic pain. [CORRECT]
C. Developing a nursing care plan for a client newly diagnosed with diabetes.
D. Teaching a client how to perform self-catheterization.
Correct Answer: B
1
,Rationale: Administering oral medications is within the scope of an LPN. The RN is responsible for initial
assessments, developing care plans, and client education, as these require the advanced assessment skills and
clinical judgment unique to RN practice. Delegating these tasks to an LPN would exceed the LPN's scope.
Q5: A nurse is caring for a client who has an advance directive stating 'Do Not
Resuscitate' (DNR). The client's family members insist that the nurse perform CPR if
the client's heart stops. Which of the following actions should the nurse take?
A. Follow the family's wishes because they are the client's next of kin.
B. Perform CPR until the provider can be reached for clarification.
C. Honor the client's advance directive and do not initiate CPR. [CORRECT]
D. Call the hospital ethics committee before taking any action.
Correct Answer: C
Rationale: An advance directive is a legally binding document that reflects the client's autonomous wishes. The
nurse must honor the DNR order and should not initiate CPR. Family members cannot override a competent client's
advance directive. The nurse should support the family emotionally but uphold the client's documented wishes.
Q6: Which of the following situations constitutes an example of negligence?
A. A nurse administers a medication as prescribed, and the client develops an unexpected allergic
reaction.
B. A nurse fails to check a client's blood glucose level before administering insulin,
resulting in hypoglycemia. [CORRECT]
C. A nurse discusses a client's diagnosis with the client's spouse who is present during the visit.
D. A nurse delegates vital signs to an AP and the AP reports an elevated temperature to the
nurse.
Correct Answer: B
Rationale: Negligence requires four elements: duty, breach of duty, causation, and damages. The nurse had a
duty to check blood glucose before administering insulin, breached that duty by failing to do so, directly caused
the hypoglycemia, and the client suffered harm (damages). An unexpected allergic reaction to a correctly
administered medication is not negligence, and sharing information with a spouse present during the visit is
generally permitted.
Q7: A nurse is caring for a client who is placed in soft wrist restraints. Which of the
following actions by the nurse is appropriate?
A. Tie the restraints to the side rails of the bed for security.
B. Remove the restraints every 2 hours to assess skin integrity and circulation for an adult client.
C. Obtain a renewal of the restraint order every 4 hours for an adult client. [CORRECT]
D. Apply the restraints tightly to prevent the client from pulling at the IV line.
Correct Answer: C
Rationale: For adult clients, a restraint order must be renewed every 4 hours. Restraints should be tied to a
movable portion of the bed frame (not side rails), removed and range of motion performed at least every 2 hours,
and secured loosely enough to allow two fingers to slip underneath. Monitoring neurovascular status should occur
every 15 to 30 minutes.
Q8: A nurse receives a telephone call from a person who identifies himself as a client's
employer and requests information about the client's diagnosis and expected return
date. Which of the following responses should the nurse make?
A. Provide the information since the employer may have a legitimate need to know.
B. Verify the caller's identity and then provide the information.
2
, C. Inform the caller that client information cannot be disclosed without the client's
written authorization. [CORRECT]
D. Transfer the call to the client's room so the employer can ask the client directly.
Correct Answer: C
Rationale: HIPAA prohibits disclosure of protected health information (PHI) to anyone without the client's written
authorization. The nurse must not provide any information about the client's diagnosis, condition, or expected
discharge to the employer. Even verifying identity is insufficient; written authorization from the client is required
before any PHI can be shared.
Q9: A nurse delegates a task to an assistive personnel. Which of the following is the
most important component of the right direction and communication?
A. Providing the AP with a written list of all tasks for the shift.
B. Telling the AP to report any abnormal findings to the nurse immediately. [CORRECT]
C. Asking the AP to follow the same routine used on the previous shift.
D. Documenting in the chart that the task was delegated to the AP.
Correct Answer: B
Rationale: The right direction and communication includes providing clear instructions, including what to do, how
to do it, and what to report back to the nurse. The most critical element is telling the AP what findings to report
back immediately so the nurse can intervene appropriately. This ensures safe, timely client care and is a core
component of the Five Rights of Delegation.
Q10: A nurse is caring for a 7-year-old child who has been placed in restraints. How
often should the nurse obtain a renewal of the restraint order for this client?
A. Every 1 hour. [CORRECT]
B. Every 2 hours.
C. Every 4 hours.
D. Every 8 hours.
Correct Answer: A
Rationale: For children under 9 years of age, a restraint order must be renewed every 1 hour. For adolescents
aged 9 to 17 years, renewal is required every 2 hours. For adults (18 years and older), the renewal period is every
4 hours. These CMS/Joint Commission requirements ensure frequent reassessment of the continued need for
restraints in younger clients.
Q11: A nurse observes a colleague arriving for the night shift appearing intoxicated
and smelling of alcohol. Which of the following actions should the nurse take first?
A. Confront the colleague and ask them to go home.
B. Report the observation to the nursing supervisor immediately. [CORRECT]
C. Allow the colleague to work but assign them only non-critical tasks.
D. Document the observation in the colleague's personnel file.
Correct Answer: B
Rationale: The nurse has a mandatory reporting obligation regarding impaired colleagues. The first action is to
report the observation to the nursing supervisor immediately to protect client safety. The supervisor is responsible
for further investigation and action. The nurse should not confront the colleague alone, allow them to work in any
capacity, or document in a personnel file, as these are not the appropriate channels.
Q12: A client who is 17 years old is admitted to the hospital for treatment of a
fractured femur. The client's parents are not available, and the surgeon needs to
perform emergency surgery. In this situation, which of the following is true regarding
informed consent?
3
