ATI Fundamentals Proctored Assessment
| Question 1-200 |Advanced/Hard Difficulty | Comprehensive Exam Bank | 100%
Pass Guaranteed | Graded A+
Question 1
A nurse is caring for a client who has a central venous catheter and develops chills,
fever, and hypotension. Which of the following actions should the nurse take first?
A. Administer antipyretics
B. Obtain blood cultures
C. Notify the provider
D. Discontinue the catheter
Valid answer: D
Explanation: Signs of catheter-related bloodstream infection (CRBSI) require
immediate removal of the suspected central line to prevent further contamination
and septic shock. Blood cultures should be obtained from the catheter and a
peripheral site before initiating antibiotics, but removing the catheter is the
priority to eliminate the source of infection.
Question 2
A nurse is providing discharge teaching to a client who has a new prescription for
enoxaparin. Which of the following statements by the client indicates
understanding?
A. "I will massage the injection site after administration."
[Date] 1
,B. "I will inject the medication into the subcutaneous tissue of my abdomen."
C. "I will expel the air bubble from the syringe before injection."
D. "I will use a 3-inch needle for the injection."
Valid answer: B
Explanation: Enoxaparin is administered subcutaneously in the abdomen,
rotating sites. The air bubble should not be expelled as it ensures full medication
delivery. Massaging the site can cause bruising. A short (⅝-inch) needle is used for
subcutaneous injections.
Question 3
A nurse is assessing a client who has a new diagnosis of hypokalemia. Which of
the following findings should the nurse expect?
A. Hyperreflexia
B. Muscle weakness
C. Tachycardia
D. Hypertension
Valid answer: B
Explanation: Hypokalemia causes muscle weakness, hyporeflexia, cardiac
arrhythmias, and hypotension. Hyperreflexia, tachycardia, and hypertension are
not typical findings in hypokalemia.
Question 4
A nurse is planning care for a group of clients. Which of the following tasks should
[Date] 2
,the nurse delegate to an assistive personnel (AP)?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client's response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. Providing postmortem care to a client
Valid answer: D
Explanation: Providing postmortem care is a routine, noninvasive task that can
be delegated to AP. Dressing changes for stage 3 pressure injuries, assessment of
diuretic response, and pulse comparison require licensed nursing judgment and
cannot be delegated.
Question 5
A nurse is caring for a client who has influenza and is on isolation precautions.
Which of the following actions should the nurse take to prevent the spread of
infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room
D. Place the client in a negative airflow room
Valid answer: A
Explanation: Influenza requires droplet precautions. A mask should be worn
when working within 3 feet of the client. Negative airflow rooms are for airborne
[Date] 3
, precautions. Metronidazole is an antibiotic, not an antiviral, and is not indicated
for influenza.
Question 6
A nurse obtains a prescription for wrist restraints for a client who is trying to pull
out his NG tube. Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client's bed
B. Apply the restraints to allow as little movement as possible
C. Allow room for two fingers to fit between the client's skin and the restraints
D. Remove the restraints every 4 hours
Valid answer: C
Explanation: Restraints should allow two fingers to fit between the restraint and
the client's skin to prevent circulatory impairment. Restraints should be attached
to the bed frame, not side rails. They should allow some movement and be
removed every 2 hours for range of motion and skin assessment.
Question 7
A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airborne
C. Protective environment
D. Contact
[Date] 4
| Question 1-200 |Advanced/Hard Difficulty | Comprehensive Exam Bank | 100%
Pass Guaranteed | Graded A+
Question 1
A nurse is caring for a client who has a central venous catheter and develops chills,
fever, and hypotension. Which of the following actions should the nurse take first?
A. Administer antipyretics
B. Obtain blood cultures
C. Notify the provider
D. Discontinue the catheter
Valid answer: D
Explanation: Signs of catheter-related bloodstream infection (CRBSI) require
immediate removal of the suspected central line to prevent further contamination
and septic shock. Blood cultures should be obtained from the catheter and a
peripheral site before initiating antibiotics, but removing the catheter is the
priority to eliminate the source of infection.
Question 2
A nurse is providing discharge teaching to a client who has a new prescription for
enoxaparin. Which of the following statements by the client indicates
understanding?
A. "I will massage the injection site after administration."
[Date] 1
,B. "I will inject the medication into the subcutaneous tissue of my abdomen."
C. "I will expel the air bubble from the syringe before injection."
D. "I will use a 3-inch needle for the injection."
Valid answer: B
Explanation: Enoxaparin is administered subcutaneously in the abdomen,
rotating sites. The air bubble should not be expelled as it ensures full medication
delivery. Massaging the site can cause bruising. A short (⅝-inch) needle is used for
subcutaneous injections.
Question 3
A nurse is assessing a client who has a new diagnosis of hypokalemia. Which of
the following findings should the nurse expect?
A. Hyperreflexia
B. Muscle weakness
C. Tachycardia
D. Hypertension
Valid answer: B
Explanation: Hypokalemia causes muscle weakness, hyporeflexia, cardiac
arrhythmias, and hypotension. Hyperreflexia, tachycardia, and hypertension are
not typical findings in hypokalemia.
Question 4
A nurse is planning care for a group of clients. Which of the following tasks should
[Date] 2
,the nurse delegate to an assistive personnel (AP)?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client's response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. Providing postmortem care to a client
Valid answer: D
Explanation: Providing postmortem care is a routine, noninvasive task that can
be delegated to AP. Dressing changes for stage 3 pressure injuries, assessment of
diuretic response, and pulse comparison require licensed nursing judgment and
cannot be delegated.
Question 5
A nurse is caring for a client who has influenza and is on isolation precautions.
Which of the following actions should the nurse take to prevent the spread of
infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room
D. Place the client in a negative airflow room
Valid answer: A
Explanation: Influenza requires droplet precautions. A mask should be worn
when working within 3 feet of the client. Negative airflow rooms are for airborne
[Date] 3
, precautions. Metronidazole is an antibiotic, not an antiviral, and is not indicated
for influenza.
Question 6
A nurse obtains a prescription for wrist restraints for a client who is trying to pull
out his NG tube. Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client's bed
B. Apply the restraints to allow as little movement as possible
C. Allow room for two fingers to fit between the client's skin and the restraints
D. Remove the restraints every 4 hours
Valid answer: C
Explanation: Restraints should allow two fingers to fit between the restraint and
the client's skin to prevent circulatory impairment. Restraints should be attached
to the bed frame, not side rails. They should allow some movement and be
removed every 2 hours for range of motion and skin assessment.
Question 7
A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airborne
C. Protective environment
D. Contact
[Date] 4
