ATI RN Fundamentals Final Exam
Questions and Correct Answers
(Verified Answers) Plus Rationales |
2026 /2027 Q&A | Instant Download
Pdf.
1. A nurse is caring for a client who is at risk for falls. Which intervention
should the nurse implement first?
A. Place the client's belongings on the bedside table.
B. Encourage the client to ambulate independently.
C. Place the bed in the lowest position with the wheels locked.
D. Apply a vest restraint when the client attempts to get out of bed.
Rationale: Keeping the bed in the lowest position with the wheels locked
reduces the risk of injury from falls and provides a stable environment.
Frequently used items should also be within reach, but the immediate
priority is establishing a safe bed position. Restraints should not be used
simply for fall prevention and require appropriate assessment and
authorization.
2. A nurse is preparing to administer an oral medication to a client.
Which action is most important for preventing a medication error?
,A. Ask the client whether the medication looks familiar.
B. Compare the medication label with the medication administration
record three times.
C. Document administration before giving the medication.
D. Leave the medication at the bedside for the client to take later.
Rationale: Comparing the medication label with the medication
administration record during preparation and administration helps
verify the correct medication, dose, route, and timing. The client should
not be relied upon to identify medications, documentation should occur
after administration, and medications should not be left unattended
unless specifically permitted by policy.
3. A nurse is performing a sterile dressing change. Which action
contaminates the sterile field?
A. Keeping sterile objects above waist level.
B. Opening the sterile package away from the body first.
C. Allowing the sterile-gloved hand to fall below waist level.
D. Keeping the sterile field within the nurse's view.
Rationale: Anything below waist level is considered contaminated
because it cannot be continuously visualized and maintained as sterile.
Sterile supplies should remain above waist level and within the nurse's
field of vision throughout the procedure.
4. A nurse is assessing a client's pain. Which finding is considered the
most reliable indicator of pain intensity?
,A. Facial expression
B. Vital-sign changes
C. Body posture
D. The client's self-report
Rationale: Pain is subjective, and the client's self-report is the most
reliable indicator when the client can communicate. Physiologic and
behavioral findings can support the assessment but should not replace
the client's report.
5. A nurse is caring for a client who has dysphagia following a stroke.
Which intervention is appropriate?
A. Offer thin liquids with meals.
B. Encourage the client to tilt the head backward when swallowing.
C. Position the client upright at 90° during meals.
D. Encourage the client to drink through a straw.
Rationale: Upright positioning decreases the risk of aspiration during
swallowing. Depending on the swallowing evaluation, thickened liquids
may be prescribed. Head positioning should follow the
recommendations of the swallowing specialist, and straws can increase
aspiration risk for some clients.
6. A nurse is caring for a client who is receiving oxygen by nasal cannula.
Which action is appropriate?
A. Apply petroleum jelly to the nares.
B. Increase the oxygen flow rate whenever the client reports dyspnea.
, C. Assess the client's respiratory status and oxygen saturation
regularly.
D. Remove the oxygen during sleep to prevent oxygen toxicity.
Rationale: Clients receiving oxygen require ongoing assessment of
respiratory status, oxygen saturation, and response to therapy.
Petroleum-based products should be avoided around oxygen because of
fire risk. Oxygen flow should be adjusted according to the prescription or
protocol rather than independently increased by the nurse.
7. A nurse is transferring a client from the bed to a wheelchair. Which
action should the nurse take?
A. Position the wheelchair several feet from the bed.
B. Leave the wheelchair unlocked during the transfer.
C. Lock the wheelchair wheels before assisting the client.
D. Have the client stand before applying nonskid footwear.
Rationale: Locking the wheelchair wheels prevents movement during
transfer and reduces the risk of falls. The wheelchair should be
positioned close to the bed, and the client should wear appropriate
nonskid footwear before standing.
8. A nurse is caring for a client with an indwelling urinary catheter.
Which intervention helps prevent catheter-associated urinary tract
infection?
A. Disconnect the drainage tubing every shift to clean it.
B. Keep the drainage bag above the level of the bladder.
Questions and Correct Answers
(Verified Answers) Plus Rationales |
2026 /2027 Q&A | Instant Download
Pdf.
1. A nurse is caring for a client who is at risk for falls. Which intervention
should the nurse implement first?
A. Place the client's belongings on the bedside table.
B. Encourage the client to ambulate independently.
C. Place the bed in the lowest position with the wheels locked.
D. Apply a vest restraint when the client attempts to get out of bed.
Rationale: Keeping the bed in the lowest position with the wheels locked
reduces the risk of injury from falls and provides a stable environment.
Frequently used items should also be within reach, but the immediate
priority is establishing a safe bed position. Restraints should not be used
simply for fall prevention and require appropriate assessment and
authorization.
2. A nurse is preparing to administer an oral medication to a client.
Which action is most important for preventing a medication error?
,A. Ask the client whether the medication looks familiar.
B. Compare the medication label with the medication administration
record three times.
C. Document administration before giving the medication.
D. Leave the medication at the bedside for the client to take later.
Rationale: Comparing the medication label with the medication
administration record during preparation and administration helps
verify the correct medication, dose, route, and timing. The client should
not be relied upon to identify medications, documentation should occur
after administration, and medications should not be left unattended
unless specifically permitted by policy.
3. A nurse is performing a sterile dressing change. Which action
contaminates the sterile field?
A. Keeping sterile objects above waist level.
B. Opening the sterile package away from the body first.
C. Allowing the sterile-gloved hand to fall below waist level.
D. Keeping the sterile field within the nurse's view.
Rationale: Anything below waist level is considered contaminated
because it cannot be continuously visualized and maintained as sterile.
Sterile supplies should remain above waist level and within the nurse's
field of vision throughout the procedure.
4. A nurse is assessing a client's pain. Which finding is considered the
most reliable indicator of pain intensity?
,A. Facial expression
B. Vital-sign changes
C. Body posture
D. The client's self-report
Rationale: Pain is subjective, and the client's self-report is the most
reliable indicator when the client can communicate. Physiologic and
behavioral findings can support the assessment but should not replace
the client's report.
5. A nurse is caring for a client who has dysphagia following a stroke.
Which intervention is appropriate?
A. Offer thin liquids with meals.
B. Encourage the client to tilt the head backward when swallowing.
C. Position the client upright at 90° during meals.
D. Encourage the client to drink through a straw.
Rationale: Upright positioning decreases the risk of aspiration during
swallowing. Depending on the swallowing evaluation, thickened liquids
may be prescribed. Head positioning should follow the
recommendations of the swallowing specialist, and straws can increase
aspiration risk for some clients.
6. A nurse is caring for a client who is receiving oxygen by nasal cannula.
Which action is appropriate?
A. Apply petroleum jelly to the nares.
B. Increase the oxygen flow rate whenever the client reports dyspnea.
, C. Assess the client's respiratory status and oxygen saturation
regularly.
D. Remove the oxygen during sleep to prevent oxygen toxicity.
Rationale: Clients receiving oxygen require ongoing assessment of
respiratory status, oxygen saturation, and response to therapy.
Petroleum-based products should be avoided around oxygen because of
fire risk. Oxygen flow should be adjusted according to the prescription or
protocol rather than independently increased by the nurse.
7. A nurse is transferring a client from the bed to a wheelchair. Which
action should the nurse take?
A. Position the wheelchair several feet from the bed.
B. Leave the wheelchair unlocked during the transfer.
C. Lock the wheelchair wheels before assisting the client.
D. Have the client stand before applying nonskid footwear.
Rationale: Locking the wheelchair wheels prevents movement during
transfer and reduces the risk of falls. The wheelchair should be
positioned close to the bed, and the client should wear appropriate
nonskid footwear before standing.
8. A nurse is caring for a client with an indwelling urinary catheter.
Which intervention helps prevent catheter-associated urinary tract
infection?
A. Disconnect the drainage tubing every shift to clean it.
B. Keep the drainage bag above the level of the bladder.
