ATI Fundamentals Clinical Judgment Practice Exam
|Questions |Answers |Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse discovers a small fire in a trash can in a client’s room. Which of the
following actions should the nurse take first?
A. Move the client to a safe location.
B. Pull the fire alarm to notify the facility.
C. Close the door to the client’s room.
D. Extinguish the fire using a fire extinguisher.
Answer: A
Rationale: According to the RACE mnemonic, the first action in a fire is Rescue/Remove
the client from immediate danger.
2. A nurse is preparing to administer an intramuscular injection to a client.
Which of the following is the priority action for the nurse to take?
A. Select the appropriate needle gauge for the medication.
B. Verify the client’s identity using two identifiers.
C. Cleanse the injection site with an antiseptic swab.
D. Document the administration in the medical record.
Answer: B
Rationale: The first of the ‘rights’ of medication administration is ensuring the right client
to prevent errors.
,3. A nurse is caring for a client who is at risk for falls. Which of the following
interventions should the nurse include in the plan of care?
A. Keep the bed in the highest position.
B. Apply physical restraints to the client’s wrists.
C. Instruct the client to use the call light for assistance.
D. Turn off the lights in the client’s room at night.
Answer: C
Rationale: Encouraging the use of the call light ensures the client can request help before
attempting to get up alone.
4. A nurse is performing a physical assessment on a client. Which technique
should the nurse use first when assessing the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Auscultation
Answer: C
Rationale: For abdominal assessment, the order is inspection, auscultation, percussion,
and palpation to avoid altering bowel sounds.
5. A nurse is caring for a client who has a prescription for a clear liquid diet.
Which of the following food items should the nurse offer?
A. Fat-free broth
B. Orange juice with pulp
C. Vanilla pudding
D. Pureed applesauce
Answer: A
Rationale: Clear liquids are those that are transparent at room temperature; broth is
acceptable, while pudding and pulp are not.
, 6. A nurse is teaching a client about using a cane. Which of the following
instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Move the cane and the stronger leg forward together.
C. Advance the cane 30 cm (12 in) ahead of the feet.
D. Hold the cane on the stronger side of the body.
Answer: D
Rationale: The cane should be held on the unaffected (stronger) side to provide support
and stability for the opposite leg.
7. A nurse is providing discharge teaching to a client who requires home oxygen
therapy. Which of the following statements by the client indicates an
understanding?
A. ‘I will use wool blankets to keep warm.’
B. ‘I can use petroleum jelly on my lips if they get dry.’
C. ‘I will check my oxygen tank level daily.’
D. ‘I can smoke if I stay at least 3 feet away from the tank.’
Answer: C
Rationale: Daily monitoring of oxygen levels is essential for safety. Wool and petroleum
are flammable and smoking is strictly prohibited.
8. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. ‘Client reports feeling nauseated.’
B. ‘Client’s skin is warm and dry to the touch.’
C. ‘Client states, I am worried about my surgery.’
D. ‘Client complains of a headache rated 5 on a 1-10 scale.’
Answer: B
|Questions |Answers |Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse discovers a small fire in a trash can in a client’s room. Which of the
following actions should the nurse take first?
A. Move the client to a safe location.
B. Pull the fire alarm to notify the facility.
C. Close the door to the client’s room.
D. Extinguish the fire using a fire extinguisher.
Answer: A
Rationale: According to the RACE mnemonic, the first action in a fire is Rescue/Remove
the client from immediate danger.
2. A nurse is preparing to administer an intramuscular injection to a client.
Which of the following is the priority action for the nurse to take?
A. Select the appropriate needle gauge for the medication.
B. Verify the client’s identity using two identifiers.
C. Cleanse the injection site with an antiseptic swab.
D. Document the administration in the medical record.
Answer: B
Rationale: The first of the ‘rights’ of medication administration is ensuring the right client
to prevent errors.
,3. A nurse is caring for a client who is at risk for falls. Which of the following
interventions should the nurse include in the plan of care?
A. Keep the bed in the highest position.
B. Apply physical restraints to the client’s wrists.
C. Instruct the client to use the call light for assistance.
D. Turn off the lights in the client’s room at night.
Answer: C
Rationale: Encouraging the use of the call light ensures the client can request help before
attempting to get up alone.
4. A nurse is performing a physical assessment on a client. Which technique
should the nurse use first when assessing the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Auscultation
Answer: C
Rationale: For abdominal assessment, the order is inspection, auscultation, percussion,
and palpation to avoid altering bowel sounds.
5. A nurse is caring for a client who has a prescription for a clear liquid diet.
Which of the following food items should the nurse offer?
A. Fat-free broth
B. Orange juice with pulp
C. Vanilla pudding
D. Pureed applesauce
Answer: A
Rationale: Clear liquids are those that are transparent at room temperature; broth is
acceptable, while pudding and pulp are not.
, 6. A nurse is teaching a client about using a cane. Which of the following
instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Move the cane and the stronger leg forward together.
C. Advance the cane 30 cm (12 in) ahead of the feet.
D. Hold the cane on the stronger side of the body.
Answer: D
Rationale: The cane should be held on the unaffected (stronger) side to provide support
and stability for the opposite leg.
7. A nurse is providing discharge teaching to a client who requires home oxygen
therapy. Which of the following statements by the client indicates an
understanding?
A. ‘I will use wool blankets to keep warm.’
B. ‘I can use petroleum jelly on my lips if they get dry.’
C. ‘I will check my oxygen tank level daily.’
D. ‘I can smoke if I stay at least 3 feet away from the tank.’
Answer: C
Rationale: Daily monitoring of oxygen levels is essential for safety. Wool and petroleum
are flammable and smoking is strictly prohibited.
8. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. ‘Client reports feeling nauseated.’
B. ‘Client’s skin is warm and dry to the touch.’
C. ‘Client states, I am worried about my surgery.’
D. ‘Client complains of a headache rated 5 on a 1-10 scale.’
Answer: B
