ATI FUNDAMENTALS CMS PROCTORED EXAM– QUESTIONS
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1. A nurse is caring for a client who has a prescription for a clear liquid diet following
abdominal surgery. Which of the following items should the nurse include on the client's
meal tray?
A. Vanilla custard
B. Vegetable broth
C. Cream of wheat
D. Orange juice with pulp
Vegetable broth is an appropriate clear liquid because it is transparent at room or body
temperature, leaves minimal residue in the gastrointestinal tract, and provides essential fluids
and electrolytes. Custard and cream of wheat are components of a full liquid diet, and orange
juice with pulp contains residue that violates clear liquid restrictions.
2. A nurse is preparing to administer an intramuscular injection to an adult client. Which
of the following sites is the preferred location for administering this injection due to the
lack of major nerves and blood vessels?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
D. Rectus femoris
The ventrogluteal site is the preferred and safest site for intramuscular injections in adults
because it is deep, away from major nerves and blood vessels, and has a thick muscle mass.
The dorsogluteal site carries a risk of striking the sciatic nerve or superior gluteal artery. The
vastus lateralis is frequently used for infants, and the rectus femoris is less commonly used
due to client discomfort.
3. A nurse is assessing a client who has been immobile for three weeks. Which of the
following findings should the nurse identify as a complication of immobility?
A. Increased muscle tone
,B. Decreased heart rate at rest
C. Urinary stasis
D. Elevated serum albumin levels
Immobility places the client at risk for urinary stasis due to the horizontal position, which
reduces bladder emptying and increases the risk of urinary tract infections and renal calculi.
Immobility leads to muscle atrophy rather than increased tone, an increased resting heart rate
due to deconditioning, and decreased serum albumin due to catabolism.
4. A nurse is applying a sterile dressing to a surgical wound. Which of the following actions
maintains surgical asepsis?
A. Reaching across the sterile field to place a gauze pad
B. Holding sterile objects above the waist level
C. Opening the outer flap of a sterile package toward the body
D. Pouring sterile solution with the label facing away from the palm
Holding sterile items at or above waist level ensures they remain within the nurse's field of
vision and prevents contamination. Reaching across a sterile field contaminates it. The outer
flap of a sterile package should be opened away from the body first, and sterile solutions
should be poured with the label facing the palm to prevent fluid from obscuring or ruining the
label.
5. A nurse is monitoring a client who is receiving continuous enteral tube feedings. Which
of the following nursing interventions is essential to prevent aspiration?
A. Elevating the head of the bed to at least 30 degrees
B. Checking residual volume every 24 hours
C. Flushing the tube with sterile water after each medication administration
D. Warming the formula in a microwave prior to instillation
Elevating the head of the bed to 30 to 45 degrees during and for at least 30 to 60 minutes after
a continuous feeding prevents gastric reflux and aspiration. Residual volumes should be
checked more frequently (e.g., every 4 to 6 hours), warm water is used for flushes, and
formulas should never be microwaved due to uneven heating and risk of nutrient destruction.
6. A nurse is admitting a client who reports difficulty falling asleep and staying asleep for
the past month. Which of the following interventions should the nurse include in a plan to
promote sleep hygiene?
, A. Consuming a light carbohydrate snack before bedtime
B. Exercising vigorously 30 minutes before sleep
C. Watching television in bed until feeling drowsy
D. Drinking two glasses of water right before bedtime
A light carbohydrate snack can promote sleep by assisting with the transport of tryptophan
into the brain. Vigorous exercise, watching television in bed, and excessive fluid intake close
to bedtime are counterproductive and can disrupt sleep patterns.
7. A nurse is assessing an older adult client for sensory alterations. Which of the following
normal physiological changes should the nurse expect related to aging?
A. Increased production of saliva
B. Enhanced high-frequency hearing acuity
C. Decreased near vision accommodation
D. Heightened sensitivity to bitter tastes
Presbyopia, or decreased near vision accommodation due to loss of lens elasticity, is a normal
aging change. Saliva production decreases, high-frequency hearing loss (presbycusis) occurs,
and taste buds—particularly for sweet and salty—decrease, while bitter sensitivity changes
vary.
8. A nurse is teaching a client who has a new prescription for crutches about proper gait
progression when climbing stairs. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I will lead with my crutches and my affected leg when going up stairs."
B. "I will lead with my unaffected leg when going up stairs."
C. "I will keep my crutches on the lower step when bringing up my unaffected leg."
D. "I will move both crutches and both legs simultaneously up the steps."
When ascending stairs with crutches, the mnemonic "up with the good" applies: the
unaffected leg goes up first, followed by the crutches and the affected leg. When descending,
the affected leg and crutches go down first ("down with the bad").
9. A nurse is caring for a client who has a body mass index (BMI) of 32. The nurse
recognizes that this client falls into which of the following categories?
A. Normal weight
AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS
PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM
UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST |
DOWNLOAD INSTANT PDF
1. A nurse is caring for a client who has a prescription for a clear liquid diet following
abdominal surgery. Which of the following items should the nurse include on the client's
meal tray?
A. Vanilla custard
B. Vegetable broth
C. Cream of wheat
D. Orange juice with pulp
Vegetable broth is an appropriate clear liquid because it is transparent at room or body
temperature, leaves minimal residue in the gastrointestinal tract, and provides essential fluids
and electrolytes. Custard and cream of wheat are components of a full liquid diet, and orange
juice with pulp contains residue that violates clear liquid restrictions.
2. A nurse is preparing to administer an intramuscular injection to an adult client. Which
of the following sites is the preferred location for administering this injection due to the
lack of major nerves and blood vessels?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
D. Rectus femoris
The ventrogluteal site is the preferred and safest site for intramuscular injections in adults
because it is deep, away from major nerves and blood vessels, and has a thick muscle mass.
The dorsogluteal site carries a risk of striking the sciatic nerve or superior gluteal artery. The
vastus lateralis is frequently used for infants, and the rectus femoris is less commonly used
due to client discomfort.
3. A nurse is assessing a client who has been immobile for three weeks. Which of the
following findings should the nurse identify as a complication of immobility?
A. Increased muscle tone
,B. Decreased heart rate at rest
C. Urinary stasis
D. Elevated serum albumin levels
Immobility places the client at risk for urinary stasis due to the horizontal position, which
reduces bladder emptying and increases the risk of urinary tract infections and renal calculi.
Immobility leads to muscle atrophy rather than increased tone, an increased resting heart rate
due to deconditioning, and decreased serum albumin due to catabolism.
4. A nurse is applying a sterile dressing to a surgical wound. Which of the following actions
maintains surgical asepsis?
A. Reaching across the sterile field to place a gauze pad
B. Holding sterile objects above the waist level
C. Opening the outer flap of a sterile package toward the body
D. Pouring sterile solution with the label facing away from the palm
Holding sterile items at or above waist level ensures they remain within the nurse's field of
vision and prevents contamination. Reaching across a sterile field contaminates it. The outer
flap of a sterile package should be opened away from the body first, and sterile solutions
should be poured with the label facing the palm to prevent fluid from obscuring or ruining the
label.
5. A nurse is monitoring a client who is receiving continuous enteral tube feedings. Which
of the following nursing interventions is essential to prevent aspiration?
A. Elevating the head of the bed to at least 30 degrees
B. Checking residual volume every 24 hours
C. Flushing the tube with sterile water after each medication administration
D. Warming the formula in a microwave prior to instillation
Elevating the head of the bed to 30 to 45 degrees during and for at least 30 to 60 minutes after
a continuous feeding prevents gastric reflux and aspiration. Residual volumes should be
checked more frequently (e.g., every 4 to 6 hours), warm water is used for flushes, and
formulas should never be microwaved due to uneven heating and risk of nutrient destruction.
6. A nurse is admitting a client who reports difficulty falling asleep and staying asleep for
the past month. Which of the following interventions should the nurse include in a plan to
promote sleep hygiene?
, A. Consuming a light carbohydrate snack before bedtime
B. Exercising vigorously 30 minutes before sleep
C. Watching television in bed until feeling drowsy
D. Drinking two glasses of water right before bedtime
A light carbohydrate snack can promote sleep by assisting with the transport of tryptophan
into the brain. Vigorous exercise, watching television in bed, and excessive fluid intake close
to bedtime are counterproductive and can disrupt sleep patterns.
7. A nurse is assessing an older adult client for sensory alterations. Which of the following
normal physiological changes should the nurse expect related to aging?
A. Increased production of saliva
B. Enhanced high-frequency hearing acuity
C. Decreased near vision accommodation
D. Heightened sensitivity to bitter tastes
Presbyopia, or decreased near vision accommodation due to loss of lens elasticity, is a normal
aging change. Saliva production decreases, high-frequency hearing loss (presbycusis) occurs,
and taste buds—particularly for sweet and salty—decrease, while bitter sensitivity changes
vary.
8. A nurse is teaching a client who has a new prescription for crutches about proper gait
progression when climbing stairs. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I will lead with my crutches and my affected leg when going up stairs."
B. "I will lead with my unaffected leg when going up stairs."
C. "I will keep my crutches on the lower step when bringing up my unaffected leg."
D. "I will move both crutches and both legs simultaneously up the steps."
When ascending stairs with crutches, the mnemonic "up with the good" applies: the
unaffected leg goes up first, followed by the crutches and the affected leg. When descending,
the affected leg and crutches go down first ("down with the bad").
9. A nurse is caring for a client who has a body mass index (BMI) of 32. The nurse
recognizes that this client falls into which of the following categories?
A. Normal weight
