ATI RN Fundamentals
Comprehensive Review Examination
Actual Exam Review | Detailed Rationales
150 Questions | Nursing Fundamentals
Instructions: Select the best answer for each question.
All answers include detailed rationales.
Cognitive Levels: 30% Recall | 50% Application | 20% Analysis
Includes scenarios and clinical case-based questions
,1. A nurse is caring for a client who is postoperative following abdominal surgery. The client
reports pain rated 7 on a 0-to-10 scale. Which of the following actions should the nurse take first?
A. Administer prescribed analgesic medication [CORRECT]
B. Reassess the pain level in 30 minutes
C. Apply a warm compress to the surgical site
D. Encourage deep breathing exercises
Correct Answer: A
Rationale: **Correct because** administering prescribed analgesic medication is the priority action when a
client reports moderate to severe pain. Correct because the nurse should treat the client's pain promptly
using the pharmacological approach prescribed, as pain management takes priority over comfort
measures or reassessment. This matches the principle of addressing the client's immediate need for relief
following surgical intervention.
2. A nurse is reviewing the medical record of a client who has a new prescription for a
medication. Which of the following actions should the nurse take to verify the prescription?
A. Compare the prescription with the drug reference manual [CORRECT]
B. Ask the pharmacist to confirm the dosage
C. Check the client's allergies in the chart
D. Verify the prescription with the provider who wrote it
Correct Answer: A
Rationale: **Correct because** comparing the prescription with a drug reference manual ensures the
dosage, route, and frequency are within safe parameters. This matches the nursing responsibility for safe
medication administration and the standard of care requiring independent verification before giving any
new medication.
3. A nurse on a medical-surgical unit receives report on four clients. Which of the following
clients should the nurse assess first?
A. A client who is 1 day postoperative and has a temperature of 37.8 C (100 F)
B. A client who has heart failure and reports dyspnea when ambulating [CORRECT]
C. A client who is scheduled for surgery in the afternoon and needs preoperative teaching
D. A client who has diabetes mellitus and a blood glucose level of 180 mg/dL
Correct Answer: B
Rationale: **Correct because** the client with heart failure reporting dyspnea is exhibiting an acute
respiratory compromise that requires immediate assessment and intervention. Priority is given to the
client with the most unstable or life-threatening condition using the airway-breathing-circulation
framework for clinical judgment.
4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which of the following statements by the client indicates an understanding of the teaching?
A. I will eat more green leafy vegetables daily
B. I will have my blood drawn to check my INR regularly [CORRECT]
C. I will take an aspirin daily for headaches
D. I will use a safety razor for shaving
,Correct Answer: B
Rationale: **Correct because** regular INR monitoring is essential for clients taking warfarin to ensure the
therapeutic range is maintained and to prevent bleeding or clotting complications. This matches the
expected client behavior for safe anticoagulant therapy management at home.
5. A nurse is caring for a client who has a terminal illness. The client states, 'I am ready to die.'
Which of the following responses by the nurse is most appropriate?
A. You have so much to live for
B. Can you tell me more about what you are feeling? [CORRECT]
C. I understand how you feel completely
D. Let's talk about something positive instead
Correct Answer: B
Rationale: **Correct because** using a therapeutic open-ended response encourages the client to express
their feelings and concerns further. This matches the principles of therapeutic communication by
acknowledging the client's statement and promoting further dialogue about their end-of-life experience.
6. A nurse is planning care for a client who has a new tracheostomy. Which of the following
interventions should the nurse include in the plan?
A. Suction the tracheostomy tube every 2 hours routinely
B. Clean the inner cannula with half-strength hydrogen peroxide
C. Change the tracheostomy ties daily or when soiled [CORRECT]
D. Apply a petroleum-based ointment around the stoma site
Correct Answer: C
Rationale: **Correct because** tracheostomy ties should be changed daily or whenever they become soiled
to maintain cleanliness and prevent skin breakdown. This matches best practice for tracheostomy care to
reduce the risk of infection and ensure secure tube placement at the stoma site.
7. A nurse is reviewing the laboratory results of a client who is receiving total parenteral
nutrition (TPN). Which of the following findings should the nurse report to the provider
immediately?
A. Blood glucose level of 210 mg/dL [CORRECT]
B. Triglyceride level of 250 mg/dL
C. BUN level of 18 mg/dL
D. Prealbumin level of 15 mg/dL
Correct Answer: A
Rationale: **Correct because** a blood glucose level of 210 mg/dL indicates hyperglycemia, which is a
common and potentially serious complication of TPN therapy due to the high dextrose content. Priority is
given to reporting this finding immediately because untreated hyperglycemia can lead to osmotic diuresis,
dehydration, and electrolyte imbalances.
8. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which of
the following muscles is most appropriate for administering a large volume of medication?
A. Deltoid
, B. Ventrogluteal [CORRECT]
C. Vastus lateralis
D. Dorsogluteal
Correct Answer: B
Rationale: **Correct because** the ventrogluteal site is the preferred location for IM injections of larger
volumes in adults due to its deep muscle mass and distance from major blood vessels and nerves. This
matches evidence-based practice for safe intramuscular medication administration in the adult
population.
9. A nurse is caring for a client who has a fecal impaction. Which of the following interventions
should the nurse anticipate implementing?
A. Administering a stimulant laxative orally
B. Performing a digital disimpaction [CORRECT]
C. Providing a high-fiber diet immediately
D. Encouraging increased fluid intake only
Correct Answer: B
Rationale: **Correct because** digital disimpaction is the direct and effective method for removing a fecal
impaction when conservative measures have failed. This matches the clinical standard of care for treating
severe fecal impaction that cannot be resolved with oral laxatives or dietary modifications alone.
10. A nurse is teaching a client about the Braden Scale. Which of the following statements by the
client indicates an understanding of the purpose of this tool?
A. It measures how much pain I am having
B. It evaluates my risk for developing pressure injuries [CORRECT]
C. It calculates my nutritional needs
D. It determines my ability to walk independently
Correct Answer: B
Rationale: **Correct because** the Braden Scale is a validated assessment tool used to evaluate a client's
risk for developing pressure injuries based on sensory perception, moisture, activity, mobility, nutrition,
and friction/shear factors. This matches the tool's purpose in clinical practice for pressure injury
prevention planning.
A nurse is caring for a client who has diabetes mellitus and a chronic wound on the lower extremity
that is not healing properly.
11. Apply a sterile dressing moistened with normal saline
A. Clean the wound with hydrogen peroxide
B. Cover the wound with a dry gauze dressing only
C. Use an adhesive tape directly on the wound edges
Correct Answer: D
Rationale: **Correct because** applying a moist sterile saline dressing promotes wound healing by
maintaining a moist wound environment, which facilitates cell migration and autolytic debridement. This
matches the evidence-based principle of moist wound healing for chronic wound management.
Comprehensive Review Examination
Actual Exam Review | Detailed Rationales
150 Questions | Nursing Fundamentals
Instructions: Select the best answer for each question.
All answers include detailed rationales.
Cognitive Levels: 30% Recall | 50% Application | 20% Analysis
Includes scenarios and clinical case-based questions
,1. A nurse is caring for a client who is postoperative following abdominal surgery. The client
reports pain rated 7 on a 0-to-10 scale. Which of the following actions should the nurse take first?
A. Administer prescribed analgesic medication [CORRECT]
B. Reassess the pain level in 30 minutes
C. Apply a warm compress to the surgical site
D. Encourage deep breathing exercises
Correct Answer: A
Rationale: **Correct because** administering prescribed analgesic medication is the priority action when a
client reports moderate to severe pain. Correct because the nurse should treat the client's pain promptly
using the pharmacological approach prescribed, as pain management takes priority over comfort
measures or reassessment. This matches the principle of addressing the client's immediate need for relief
following surgical intervention.
2. A nurse is reviewing the medical record of a client who has a new prescription for a
medication. Which of the following actions should the nurse take to verify the prescription?
A. Compare the prescription with the drug reference manual [CORRECT]
B. Ask the pharmacist to confirm the dosage
C. Check the client's allergies in the chart
D. Verify the prescription with the provider who wrote it
Correct Answer: A
Rationale: **Correct because** comparing the prescription with a drug reference manual ensures the
dosage, route, and frequency are within safe parameters. This matches the nursing responsibility for safe
medication administration and the standard of care requiring independent verification before giving any
new medication.
3. A nurse on a medical-surgical unit receives report on four clients. Which of the following
clients should the nurse assess first?
A. A client who is 1 day postoperative and has a temperature of 37.8 C (100 F)
B. A client who has heart failure and reports dyspnea when ambulating [CORRECT]
C. A client who is scheduled for surgery in the afternoon and needs preoperative teaching
D. A client who has diabetes mellitus and a blood glucose level of 180 mg/dL
Correct Answer: B
Rationale: **Correct because** the client with heart failure reporting dyspnea is exhibiting an acute
respiratory compromise that requires immediate assessment and intervention. Priority is given to the
client with the most unstable or life-threatening condition using the airway-breathing-circulation
framework for clinical judgment.
4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which of the following statements by the client indicates an understanding of the teaching?
A. I will eat more green leafy vegetables daily
B. I will have my blood drawn to check my INR regularly [CORRECT]
C. I will take an aspirin daily for headaches
D. I will use a safety razor for shaving
,Correct Answer: B
Rationale: **Correct because** regular INR monitoring is essential for clients taking warfarin to ensure the
therapeutic range is maintained and to prevent bleeding or clotting complications. This matches the
expected client behavior for safe anticoagulant therapy management at home.
5. A nurse is caring for a client who has a terminal illness. The client states, 'I am ready to die.'
Which of the following responses by the nurse is most appropriate?
A. You have so much to live for
B. Can you tell me more about what you are feeling? [CORRECT]
C. I understand how you feel completely
D. Let's talk about something positive instead
Correct Answer: B
Rationale: **Correct because** using a therapeutic open-ended response encourages the client to express
their feelings and concerns further. This matches the principles of therapeutic communication by
acknowledging the client's statement and promoting further dialogue about their end-of-life experience.
6. A nurse is planning care for a client who has a new tracheostomy. Which of the following
interventions should the nurse include in the plan?
A. Suction the tracheostomy tube every 2 hours routinely
B. Clean the inner cannula with half-strength hydrogen peroxide
C. Change the tracheostomy ties daily or when soiled [CORRECT]
D. Apply a petroleum-based ointment around the stoma site
Correct Answer: C
Rationale: **Correct because** tracheostomy ties should be changed daily or whenever they become soiled
to maintain cleanliness and prevent skin breakdown. This matches best practice for tracheostomy care to
reduce the risk of infection and ensure secure tube placement at the stoma site.
7. A nurse is reviewing the laboratory results of a client who is receiving total parenteral
nutrition (TPN). Which of the following findings should the nurse report to the provider
immediately?
A. Blood glucose level of 210 mg/dL [CORRECT]
B. Triglyceride level of 250 mg/dL
C. BUN level of 18 mg/dL
D. Prealbumin level of 15 mg/dL
Correct Answer: A
Rationale: **Correct because** a blood glucose level of 210 mg/dL indicates hyperglycemia, which is a
common and potentially serious complication of TPN therapy due to the high dextrose content. Priority is
given to reporting this finding immediately because untreated hyperglycemia can lead to osmotic diuresis,
dehydration, and electrolyte imbalances.
8. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which of
the following muscles is most appropriate for administering a large volume of medication?
A. Deltoid
, B. Ventrogluteal [CORRECT]
C. Vastus lateralis
D. Dorsogluteal
Correct Answer: B
Rationale: **Correct because** the ventrogluteal site is the preferred location for IM injections of larger
volumes in adults due to its deep muscle mass and distance from major blood vessels and nerves. This
matches evidence-based practice for safe intramuscular medication administration in the adult
population.
9. A nurse is caring for a client who has a fecal impaction. Which of the following interventions
should the nurse anticipate implementing?
A. Administering a stimulant laxative orally
B. Performing a digital disimpaction [CORRECT]
C. Providing a high-fiber diet immediately
D. Encouraging increased fluid intake only
Correct Answer: B
Rationale: **Correct because** digital disimpaction is the direct and effective method for removing a fecal
impaction when conservative measures have failed. This matches the clinical standard of care for treating
severe fecal impaction that cannot be resolved with oral laxatives or dietary modifications alone.
10. A nurse is teaching a client about the Braden Scale. Which of the following statements by the
client indicates an understanding of the purpose of this tool?
A. It measures how much pain I am having
B. It evaluates my risk for developing pressure injuries [CORRECT]
C. It calculates my nutritional needs
D. It determines my ability to walk independently
Correct Answer: B
Rationale: **Correct because** the Braden Scale is a validated assessment tool used to evaluate a client's
risk for developing pressure injuries based on sensory perception, moisture, activity, mobility, nutrition,
and friction/shear factors. This matches the tool's purpose in clinical practice for pressure injury
prevention planning.
A nurse is caring for a client who has diabetes mellitus and a chronic wound on the lower extremity
that is not healing properly.
11. Apply a sterile dressing moistened with normal saline
A. Clean the wound with hydrogen peroxide
B. Cover the wound with a dry gauze dressing only
C. Use an adhesive tape directly on the wound edges
Correct Answer: D
Rationale: **Correct because** applying a moist sterile saline dressing promotes wound healing by
maintaining a moist wound environment, which facilitates cell migration and autolytic debridement. This
matches the evidence-based principle of moist wound healing for chronic wound management.
