RN ATI FUNDAMENTALS OF
NURSING PROCTORED EXAM
2023 RETAKE
1. A nurse is assessing a client who received morphine for severe pain 30
minutes ago. Which finding is the nurse's priority?
A. Last bowel movement was 3 days ago.
B. Reports pain of 8 on a scale of 0 to 10.
C. Distended bladder.
D. Respiratory rate of 7/min.
Correct Answer: D
Rationale: A respiratory rate of 7/min indicates severe respiratory depression, a
life-threatening adverse effect of morphine. Airway and breathing are always the
top priority. While the other options are important, they are not immediately life-
threatening.
2. A nurse enters the room of a client who has a seizure disorder. The client is
sitting in a chair and begins to experience a seizure. Which action should the
nurse take first?
A. Move items in the room away from the client.
B. Turn the client onto their side.
C. Help the client lie on the floor.
D. Loosen the client's clothing.
Correct Answer: C
Rationale: The immediate priority is to protect the client from injury. The nurse
should first help the client lie on the floor to prevent a fall from the chair. Once
the client is on the floor, the nurse can then move items away, turn the client on
their side to maintain an airway, and loosen clothing.
,3. A nurse is caring for a client following a laparoscopic cholecystectomy. The
client has a prescription for ondansetron 4 mg IV bolus every 6 hr PRN for
nausea. What is the correct sequence of steps to administer the medication?
A. Perform hand hygiene, select the injection port closest to the client, cleanse the
port, aspirate for blood return, inject the medication.
B. Select the injection port, perform hand hygiene, cleanse the port, inject the
medication.
C. Perform hand hygiene, select the injection port farthest from the client, cleanse
the port, inject the medication.
D. Cleanse the port, select the injection port, perform hand hygiene, aspirate for
blood return, inject the medication.
Correct Answer: A
Rationale: The correct sequence for IV bolus administration is: perform hand
hygiene, select the injection port of the IV tubing closest to the client, cleanse the
injection port with an antiseptic swab, aspirate for blood return, and then inject
the medication.
4. A nurse is assessing an adult client who has been immobile for the past 3
weeks. The nurse should identify that which finding requires further
intervention?
A. Muscle atrophy of the lower extremities.
B. Erythema on pressure points.
C. Decreased appetite.
D. Joint stiffness.
Correct Answer: B
Rationale: Erythema (redness) on pressure points is an early sign of a pressure
injury. This requires immediate intervention, such as repositioning the client, to
prevent further skin breakdown. While muscle atrophy, decreased appetite, and
joint stiffness are also consequences of immobility, they are not as urgent as
preventing a pressure injury.
5. A nurse is caring for a client who has been treated multiple times for STIs.
Which response is therapeutic?
,A. "You must have too many sexual partners."
B. "Why do you keep letting this happen?"
C. "Let's explore why this might be reoccurring."
D. "Don't you have access to condoms?"
Correct Answer: C
Rationale: This is a non-judgmental, open-ended response that encourages
discussion and allows the client to explore the reasons for recurring STIs. It is
therapeutic and client-centered. The other responses are judgmental, accusatory,
or close-ended.
6. A nurse is performing a Romberg's test. Which technique should the nurse
use?
A. Move a vibrating tuning fork in front of the client's ear canals.
B. Place the base of a vibrating tuning fork on the client's mastoid process.
C. Have the client stand with arms at their side and feet together.
D. Count how many seconds the client can stand on one foot.
Correct Answer: C
Rationale: The Romberg's test assesses balance. The nurse should instruct the
client to stand with their arms at their sides and feet together. The nurse observes
for swaying or loss of balance.
7. A nurse is planning an education session for an older adult client who has just
learned she has type 2 diabetes mellitus. Which strategy should the nurse plan
to use?
A. Use medical terminology to ensure accuracy.
B. Provide all the information quickly before the client loses focus.
C. Allow extra time for the client to respond to questions.
D. Avoid using written materials.
Correct Answer: C
Rationale: Older adults may need more time to process new information. The
nurse should allow extra time for the client to respond to questions and should
use clear, simple language, and provide written materials for reinforcement.
, 8. A nurse is preparing to transfer a client who is partially weight-bearing from
the bed to a chair. Which action should the nurse take?
A. Keep the client's knees straight when moving.
B. Position the chair next to the bed at a 90-degree angle.
C. Stand with feet together when lifting the client.
D. Have the client bear weight on their stronger leg.
Correct Answer: D
Rationale: The client should be instructed to bear weight on their stronger leg
during the transfer to maintain balance and stability. The chair should be placed at
a 45-degree angle to the bed, not 90 degrees. The nurse should use a wide base of
support (feet shoulder-width apart) and the client's knees should be slightly bent.
9. A nurse is caring for a client who is expressing anger over his diagnosis of
colorectal cancer. Which of the following responses should the nurse make?
A. "You shouldn't be angry. It's not going to help."
B. "I understand you are feeling angry. This is a normal response."
C. "Why are you so angry? We are doing everything we can."
D. "I'm going to give you some space to calm down."
Correct Answer: B
Rationale: Acknowledging the client's feelings and normalizing their response is
therapeutic. It validates the client's emotions and opens the door for further
communication.
10. A nurse is testing a client for conduction deafness by performing Weber's
test. Which action should the nurse take?
A. Move a vibrating tuning fork in front of the client's ear canals one after the
other.
B. Place the base of a vibrating tuning fork on the client's mastoid process.
C. Place the base of a vibrating tuning fork on the top of the client's head.
D. Count how many seconds the client can hear a tuning fork.
Correct Answer: C
Rationale: For the Weber's test, the nurse places the base of a vibrating tuning
NURSING PROCTORED EXAM
2023 RETAKE
1. A nurse is assessing a client who received morphine for severe pain 30
minutes ago. Which finding is the nurse's priority?
A. Last bowel movement was 3 days ago.
B. Reports pain of 8 on a scale of 0 to 10.
C. Distended bladder.
D. Respiratory rate of 7/min.
Correct Answer: D
Rationale: A respiratory rate of 7/min indicates severe respiratory depression, a
life-threatening adverse effect of morphine. Airway and breathing are always the
top priority. While the other options are important, they are not immediately life-
threatening.
2. A nurse enters the room of a client who has a seizure disorder. The client is
sitting in a chair and begins to experience a seizure. Which action should the
nurse take first?
A. Move items in the room away from the client.
B. Turn the client onto their side.
C. Help the client lie on the floor.
D. Loosen the client's clothing.
Correct Answer: C
Rationale: The immediate priority is to protect the client from injury. The nurse
should first help the client lie on the floor to prevent a fall from the chair. Once
the client is on the floor, the nurse can then move items away, turn the client on
their side to maintain an airway, and loosen clothing.
,3. A nurse is caring for a client following a laparoscopic cholecystectomy. The
client has a prescription for ondansetron 4 mg IV bolus every 6 hr PRN for
nausea. What is the correct sequence of steps to administer the medication?
A. Perform hand hygiene, select the injection port closest to the client, cleanse the
port, aspirate for blood return, inject the medication.
B. Select the injection port, perform hand hygiene, cleanse the port, inject the
medication.
C. Perform hand hygiene, select the injection port farthest from the client, cleanse
the port, inject the medication.
D. Cleanse the port, select the injection port, perform hand hygiene, aspirate for
blood return, inject the medication.
Correct Answer: A
Rationale: The correct sequence for IV bolus administration is: perform hand
hygiene, select the injection port of the IV tubing closest to the client, cleanse the
injection port with an antiseptic swab, aspirate for blood return, and then inject
the medication.
4. A nurse is assessing an adult client who has been immobile for the past 3
weeks. The nurse should identify that which finding requires further
intervention?
A. Muscle atrophy of the lower extremities.
B. Erythema on pressure points.
C. Decreased appetite.
D. Joint stiffness.
Correct Answer: B
Rationale: Erythema (redness) on pressure points is an early sign of a pressure
injury. This requires immediate intervention, such as repositioning the client, to
prevent further skin breakdown. While muscle atrophy, decreased appetite, and
joint stiffness are also consequences of immobility, they are not as urgent as
preventing a pressure injury.
5. A nurse is caring for a client who has been treated multiple times for STIs.
Which response is therapeutic?
,A. "You must have too many sexual partners."
B. "Why do you keep letting this happen?"
C. "Let's explore why this might be reoccurring."
D. "Don't you have access to condoms?"
Correct Answer: C
Rationale: This is a non-judgmental, open-ended response that encourages
discussion and allows the client to explore the reasons for recurring STIs. It is
therapeutic and client-centered. The other responses are judgmental, accusatory,
or close-ended.
6. A nurse is performing a Romberg's test. Which technique should the nurse
use?
A. Move a vibrating tuning fork in front of the client's ear canals.
B. Place the base of a vibrating tuning fork on the client's mastoid process.
C. Have the client stand with arms at their side and feet together.
D. Count how many seconds the client can stand on one foot.
Correct Answer: C
Rationale: The Romberg's test assesses balance. The nurse should instruct the
client to stand with their arms at their sides and feet together. The nurse observes
for swaying or loss of balance.
7. A nurse is planning an education session for an older adult client who has just
learned she has type 2 diabetes mellitus. Which strategy should the nurse plan
to use?
A. Use medical terminology to ensure accuracy.
B. Provide all the information quickly before the client loses focus.
C. Allow extra time for the client to respond to questions.
D. Avoid using written materials.
Correct Answer: C
Rationale: Older adults may need more time to process new information. The
nurse should allow extra time for the client to respond to questions and should
use clear, simple language, and provide written materials for reinforcement.
, 8. A nurse is preparing to transfer a client who is partially weight-bearing from
the bed to a chair. Which action should the nurse take?
A. Keep the client's knees straight when moving.
B. Position the chair next to the bed at a 90-degree angle.
C. Stand with feet together when lifting the client.
D. Have the client bear weight on their stronger leg.
Correct Answer: D
Rationale: The client should be instructed to bear weight on their stronger leg
during the transfer to maintain balance and stability. The chair should be placed at
a 45-degree angle to the bed, not 90 degrees. The nurse should use a wide base of
support (feet shoulder-width apart) and the client's knees should be slightly bent.
9. A nurse is caring for a client who is expressing anger over his diagnosis of
colorectal cancer. Which of the following responses should the nurse make?
A. "You shouldn't be angry. It's not going to help."
B. "I understand you are feeling angry. This is a normal response."
C. "Why are you so angry? We are doing everything we can."
D. "I'm going to give you some space to calm down."
Correct Answer: B
Rationale: Acknowledging the client's feelings and normalizing their response is
therapeutic. It validates the client's emotions and opens the door for further
communication.
10. A nurse is testing a client for conduction deafness by performing Weber's
test. Which action should the nurse take?
A. Move a vibrating tuning fork in front of the client's ear canals one after the
other.
B. Place the base of a vibrating tuning fork on the client's mastoid process.
C. Place the base of a vibrating tuning fork on the top of the client's head.
D. Count how many seconds the client can hear a tuning fork.
Correct Answer: C
Rationale: For the Weber's test, the nurse places the base of a vibrating tuning
