ATI FUNDAMENTAL 2023 RETAKE QUESTIONS AND ANSWERS ALREADY GRADED A+. 100% VERIFIED
SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is preparing to administer a prescribed oral medication to a client who is dysphagic. Which action is
most appropriate?
A. Crush an extended-release tablet and mix it with applesauce.
B. Place the whole tablet in a spoonful of thickened liquid.
C. Administer the medication with a full glass of water while the client sits upright.
D. Consult the pharmacist regarding available liquid or dissolvable formulations.
🟢 Correct Answer:
D. Consult the pharmacist regarding available liquid or dissolvable formulations.
🔴 RATIONALE:
For a client with dysphagia, the safest approach is to determine whether an alternative formulation, such as a
liquid or orally disintegrating form, is available. Crushing extended-release or enteric-coated tablets can alter
drug absorption and cause toxicity. Placing a whole tablet in thickened liquid increases aspiration risk, and
administering with water while upright may not be safe if the swallowing impairment is significant.
Question 2
A nurse is documenting a client’s wound assessment. Which statement is most accurate and appropriate?
A. Wound appears to be healing well.
B. 3 cm × 2 cm wound with serosanguineous drainage, no odor noted.
C. Client states wound feels better today.
D. Dressing changed without difficulty.
,🟢 Correct Answer:
B. 3 cm × 2 cm wound with serosanguineous drainage, no odor noted.
🔴 RATIONALE:
Documentation must be objective, measurable, and descriptive. Stating the size, type of drainage, and absence
of odor provides clear, factual data. Statements that wounds “appear” to be healing or that the client “feels
better” are vague and subjective; “dressing changed without difficulty” does not describe the wound itself.
Question 3
A client on bed rest is at risk for venous thromboembolism. Which nursing intervention is most effective for
prevention?
A. Massaging the lower extremities every shift
B. Encouraging active range-of-motion exercises and applying sequential compression devices as prescribed
C. Keeping the head of the bed elevated above 45 degrees at all times
D. Restricting oral fluid intake to reduce edema
🟢 Correct Answer:
B. Encouraging active range-of-motion exercises and applying sequential compression devices as prescribed.
🔴 RATIONALE:
Active range-of-motion exercises promote venous return through muscle contraction, and sequential
compression devices enhance blood flow in the deep veins. Massaging the lower extremities is contraindicated
because it may dislodge an existing thrombus. Keeping the head of bed elevated or restricting fluids does not
directly prevent venous stasis.
Question 4
A nurse is caring for a client who has Clostridium difficile infection. Which type of precautions should the nurse
,implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
🟢 Correct Answer:
C. Contact precautions
🔴 RATIONALE:
Clostridium difficile is transmitted via spores that persist on surfaces; contact precautions, including gloves and
gown, and meticulous hand hygiene with soap and water are required. Airborne and droplet precautions are
not indicated. Standard precautions alone are insufficient for preventing transmission of this organism.
Question 5
A client is receiving continuous enteral tube feeding. Which action by the nurse is most important to prevent
aspiration?
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding.
B. Check gastric residual volume every 24 hours.
C. Add blue food coloring to the formula to detect aspiration.
D. Keep the client in a supine position during feeding.
🟢 Correct Answer:
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding.
🔴 RATIONALE:
Elevating the head of the bed to at least 30 degrees reduces the risk of reflux and aspiration during enteral
, feeding. Gastric residual volume should be checked more frequently according to facility policy. Adding blue
food coloring is no longer recommended because of potential adverse effects, and supine positioning increases
aspiration risk.
Question 6
A nurse is preparing a sterile field. Which action contaminates the field?
A. Keeping sterile items at waist level
B. Opening the outermost flap of a sterile package away from the body
C. Reaching over the sterile field to move a sterile item
D. Using sterile forceps to handle a sterile gauze sponge
🟢 Correct Answer:
C. Reaching over the sterile field to move a sterile item.
🔴 RATIONALE:
Reaching over a sterile field contaminates it because microorganisms from the nurse’s clothing or skin may fall
onto the field. Keeping items above waist level, opening the first flap away from the body, and using sterile
forceps are all correct techniques for maintaining sterility.
Question 7
A client receiving oxygen via nasal cannula at 4 L/min has dry nasal mucous membranes. Which nursing action
is best?
A. Apply petroleum jelly to the nares to soothe dryness.
B. Increase the oxygen flow rate to improve comfort.
C. Use a water-based lubricant or humidification as prescribed.
D. Discontinue oxygen until the nares are moisturized.
SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is preparing to administer a prescribed oral medication to a client who is dysphagic. Which action is
most appropriate?
A. Crush an extended-release tablet and mix it with applesauce.
B. Place the whole tablet in a spoonful of thickened liquid.
C. Administer the medication with a full glass of water while the client sits upright.
D. Consult the pharmacist regarding available liquid or dissolvable formulations.
🟢 Correct Answer:
D. Consult the pharmacist regarding available liquid or dissolvable formulations.
🔴 RATIONALE:
For a client with dysphagia, the safest approach is to determine whether an alternative formulation, such as a
liquid or orally disintegrating form, is available. Crushing extended-release or enteric-coated tablets can alter
drug absorption and cause toxicity. Placing a whole tablet in thickened liquid increases aspiration risk, and
administering with water while upright may not be safe if the swallowing impairment is significant.
Question 2
A nurse is documenting a client’s wound assessment. Which statement is most accurate and appropriate?
A. Wound appears to be healing well.
B. 3 cm × 2 cm wound with serosanguineous drainage, no odor noted.
C. Client states wound feels better today.
D. Dressing changed without difficulty.
,🟢 Correct Answer:
B. 3 cm × 2 cm wound with serosanguineous drainage, no odor noted.
🔴 RATIONALE:
Documentation must be objective, measurable, and descriptive. Stating the size, type of drainage, and absence
of odor provides clear, factual data. Statements that wounds “appear” to be healing or that the client “feels
better” are vague and subjective; “dressing changed without difficulty” does not describe the wound itself.
Question 3
A client on bed rest is at risk for venous thromboembolism. Which nursing intervention is most effective for
prevention?
A. Massaging the lower extremities every shift
B. Encouraging active range-of-motion exercises and applying sequential compression devices as prescribed
C. Keeping the head of the bed elevated above 45 degrees at all times
D. Restricting oral fluid intake to reduce edema
🟢 Correct Answer:
B. Encouraging active range-of-motion exercises and applying sequential compression devices as prescribed.
🔴 RATIONALE:
Active range-of-motion exercises promote venous return through muscle contraction, and sequential
compression devices enhance blood flow in the deep veins. Massaging the lower extremities is contraindicated
because it may dislodge an existing thrombus. Keeping the head of bed elevated or restricting fluids does not
directly prevent venous stasis.
Question 4
A nurse is caring for a client who has Clostridium difficile infection. Which type of precautions should the nurse
,implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
🟢 Correct Answer:
C. Contact precautions
🔴 RATIONALE:
Clostridium difficile is transmitted via spores that persist on surfaces; contact precautions, including gloves and
gown, and meticulous hand hygiene with soap and water are required. Airborne and droplet precautions are
not indicated. Standard precautions alone are insufficient for preventing transmission of this organism.
Question 5
A client is receiving continuous enteral tube feeding. Which action by the nurse is most important to prevent
aspiration?
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding.
B. Check gastric residual volume every 24 hours.
C. Add blue food coloring to the formula to detect aspiration.
D. Keep the client in a supine position during feeding.
🟢 Correct Answer:
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding.
🔴 RATIONALE:
Elevating the head of the bed to at least 30 degrees reduces the risk of reflux and aspiration during enteral
, feeding. Gastric residual volume should be checked more frequently according to facility policy. Adding blue
food coloring is no longer recommended because of potential adverse effects, and supine positioning increases
aspiration risk.
Question 6
A nurse is preparing a sterile field. Which action contaminates the field?
A. Keeping sterile items at waist level
B. Opening the outermost flap of a sterile package away from the body
C. Reaching over the sterile field to move a sterile item
D. Using sterile forceps to handle a sterile gauze sponge
🟢 Correct Answer:
C. Reaching over the sterile field to move a sterile item.
🔴 RATIONALE:
Reaching over a sterile field contaminates it because microorganisms from the nurse’s clothing or skin may fall
onto the field. Keeping items above waist level, opening the first flap away from the body, and using sterile
forceps are all correct techniques for maintaining sterility.
Question 7
A client receiving oxygen via nasal cannula at 4 L/min has dry nasal mucous membranes. Which nursing action
is best?
A. Apply petroleum jelly to the nares to soothe dryness.
B. Increase the oxygen flow rate to improve comfort.
C. Use a water-based lubricant or humidification as prescribed.
D. Discontinue oxygen until the nares are moisturized.
