ATI Fundamentals 2019 Proctored Exam |
Fundamentals Proctored Exam_UPDATED
2022/2023
Section 1: Foundations of Nursing Practice & the Nursing Process (Questions 1–15)
1. A nurse is caring for a client who is diaphoretic, pale, and clutching their chest while
stating, "I feel like an elephant is sitting on my chest." The nurse immediately checks vital
signs and prepares to administer oxygen. Which component of clinical judgment is the nurse
demonstrating?
A. Recognizing cues
B. Analyzing cues
C. Prioritizing hypotheses
D. Taking action
Correct Answer: D. Taking action
Rationale: The nurse has already recognized and analyzed the cues (chest pain, diaphoresis,
pallor), prioritized the hypothesis (possible myocardial infarction), and is now implementing
interventions by checking vital signs and preparing oxygen. The "Taking Action" phase of clinical
judgment involves implementing the generated solutions .
2. Which assessment finding is an example of objective data?
A. Client reports feeling dizzy
B. Client states "I have a headache"
C. Client's blood pressure is 140/90 mmHg
D. Client reports nausea
Correct Answer: C. Client's blood pressure is 140/90 mmHg
Rationale: Objective data are observable, measurable findings obtained through physical
examination or diagnostic testing. Blood pressure measurement is objective data. Subjective
data include what the client reports (dizziness, headache, nausea) .
,3. A nurse is evaluating whether a client's goal of walking to the bathroom independently has
been met. Which step of the nursing process is being performed?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: D. Evaluation
Rationale: Evaluation is the final step of the nursing process where the nurse determines
whether the client's goals have been met, partially met, or not met. This step guides
modification of the plan of care if needed .
4. A nurse is caring for a client who has just returned from surgery. Which assessment finding
requires immediate intervention?
A. Blood pressure of 110/70 mm Hg
B. Respiratory rate of 16 breaths/min
C. Oxygen saturation of 88% on room air
D. Heart rate of 82 beats/min
Correct Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires immediate
intervention, such as administering supplemental oxygen and assessing the airway. Normal
oxygen saturation should be above 95%. The other vital signs listed are within normal limits for
a postoperative client .
5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which statement by the client indicates an understanding of the teaching?
A. "I will increase my intake of green leafy vegetables."
B. "I will take ibuprofen for my headaches."
C. "I will use an electric razor for shaving."
D. "I will consume a glass of grapefruit juice daily."
Correct Answer: C. "I will use an electric razor for shaving."
Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Using an electric
razor minimizes the risk of skin nicks and bleeding compared to a straight razor. Clients should
,avoid increased intake of vitamin K-rich foods (like green leafy vegetables), NSAIDs (like
ibuprofen), and grapefruit juice, which can interact with warfarin .
6. A nurse is preparing to administer several medications to a client. Which of the following
data should the nurse plan to use to confirm the client's identity?
A. The client's room number
B. The client's admitting diagnosis
C. The name of the client's next of kin
D. The client's telephone number
Correct Answer: D. The client's telephone number
Rationale: Acceptable identifiers for client verification include the client's name, telephone
number, medical record number, or date of birth. The room number, diagnosis, and next-of-kin
name are not acceptable identifiers for medication administration .
7. A newly licensed nurse is preparing to perform an indwelling urinary catheter insertion for
the first time. Which action demonstrates the most appropriate professional practice?
A. Review the facility's policy and procedure manual
B. Read and follow the written instructions provided
C. Request a preceptor to observe the procedure
D. Ask another nurse to perform the skill
Correct Answer: C. Request a preceptor to observe the procedure
Rationale: A newly licensed nurse performing a skill for the first time should request direct
observation and supervision from a preceptor or experienced nurse to ensure patient safety and
competency verification. Direct supervision provides immediate feedback, correction of
technique, and ensures adherence to proper sterile technique .
8. A nurse is documenting in a client's medical record. Which of the following entries should
the nurse record?
A. "Oral temperature slightly elevated at 0800"
B. "Administered pain medication"
C. "Incision without redness or drainage"
D. "Drank adequate amounts of fluid with meals"
, Correct Answer: B. "Administered pain medication"
Rationale: Documentation should be objective, specific, and factual. "Administered pain
medication" is a clear, factual statement. The other options are vague and use subjective terms
like "slightly," "without," and "adequate" that do not provide measurable data .
9. A nurse is caring for a client who has a terminal illness and decides to discontinue active
treatment. What is the most appropriate therapeutic response from the nurse?
A. "Why are you choosing to give up now?"
B. "Tell me more about your decision and what led you to this choice"
C. "What does your family think about this decision?"
D. "There are still other treatment options you could consider"
Correct Answer: B. "Tell me more about your decision and what led you to this choice"
Rationale: This open-ended, nonjudgmental response invites the client to express their
thoughts and feelings while demonstrating respect for patient autonomy. It avoids value
judgments and respects patient-centered care principles .
10. A nurse is providing discharge teaching to a client who does not speak the same language
as the nurse. Which of the following actions should the nurse take?
A. Direct verbal discharge instructions to the interpreter
B. Use hand gestures and drawings to communicate
C. Ask a family member to interpret the instructions
D. Provide written instructions in the client's language only
Correct Answer: A. Direct verbal discharge instructions to the interpreter
Rationale: When using an interpreter, the nurse should direct communication to the client,
not the interpreter. Family members should not be used as interpreters due to confidentiality
and potential for misinterpretation. Written instructions alone are insufficient without verbal
teaching .
11. A nurse is caring for a client who has bilateral casts on her hands. Which action should the
nurse take when assisting the client with feeding?
A. Sit at the bedside while feeding the client
B. Feed the client quickly to prevent fatigue
Fundamentals Proctored Exam_UPDATED
2022/2023
Section 1: Foundations of Nursing Practice & the Nursing Process (Questions 1–15)
1. A nurse is caring for a client who is diaphoretic, pale, and clutching their chest while
stating, "I feel like an elephant is sitting on my chest." The nurse immediately checks vital
signs and prepares to administer oxygen. Which component of clinical judgment is the nurse
demonstrating?
A. Recognizing cues
B. Analyzing cues
C. Prioritizing hypotheses
D. Taking action
Correct Answer: D. Taking action
Rationale: The nurse has already recognized and analyzed the cues (chest pain, diaphoresis,
pallor), prioritized the hypothesis (possible myocardial infarction), and is now implementing
interventions by checking vital signs and preparing oxygen. The "Taking Action" phase of clinical
judgment involves implementing the generated solutions .
2. Which assessment finding is an example of objective data?
A. Client reports feeling dizzy
B. Client states "I have a headache"
C. Client's blood pressure is 140/90 mmHg
D. Client reports nausea
Correct Answer: C. Client's blood pressure is 140/90 mmHg
Rationale: Objective data are observable, measurable findings obtained through physical
examination or diagnostic testing. Blood pressure measurement is objective data. Subjective
data include what the client reports (dizziness, headache, nausea) .
,3. A nurse is evaluating whether a client's goal of walking to the bathroom independently has
been met. Which step of the nursing process is being performed?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: D. Evaluation
Rationale: Evaluation is the final step of the nursing process where the nurse determines
whether the client's goals have been met, partially met, or not met. This step guides
modification of the plan of care if needed .
4. A nurse is caring for a client who has just returned from surgery. Which assessment finding
requires immediate intervention?
A. Blood pressure of 110/70 mm Hg
B. Respiratory rate of 16 breaths/min
C. Oxygen saturation of 88% on room air
D. Heart rate of 82 beats/min
Correct Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires immediate
intervention, such as administering supplemental oxygen and assessing the airway. Normal
oxygen saturation should be above 95%. The other vital signs listed are within normal limits for
a postoperative client .
5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which statement by the client indicates an understanding of the teaching?
A. "I will increase my intake of green leafy vegetables."
B. "I will take ibuprofen for my headaches."
C. "I will use an electric razor for shaving."
D. "I will consume a glass of grapefruit juice daily."
Correct Answer: C. "I will use an electric razor for shaving."
Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Using an electric
razor minimizes the risk of skin nicks and bleeding compared to a straight razor. Clients should
,avoid increased intake of vitamin K-rich foods (like green leafy vegetables), NSAIDs (like
ibuprofen), and grapefruit juice, which can interact with warfarin .
6. A nurse is preparing to administer several medications to a client. Which of the following
data should the nurse plan to use to confirm the client's identity?
A. The client's room number
B. The client's admitting diagnosis
C. The name of the client's next of kin
D. The client's telephone number
Correct Answer: D. The client's telephone number
Rationale: Acceptable identifiers for client verification include the client's name, telephone
number, medical record number, or date of birth. The room number, diagnosis, and next-of-kin
name are not acceptable identifiers for medication administration .
7. A newly licensed nurse is preparing to perform an indwelling urinary catheter insertion for
the first time. Which action demonstrates the most appropriate professional practice?
A. Review the facility's policy and procedure manual
B. Read and follow the written instructions provided
C. Request a preceptor to observe the procedure
D. Ask another nurse to perform the skill
Correct Answer: C. Request a preceptor to observe the procedure
Rationale: A newly licensed nurse performing a skill for the first time should request direct
observation and supervision from a preceptor or experienced nurse to ensure patient safety and
competency verification. Direct supervision provides immediate feedback, correction of
technique, and ensures adherence to proper sterile technique .
8. A nurse is documenting in a client's medical record. Which of the following entries should
the nurse record?
A. "Oral temperature slightly elevated at 0800"
B. "Administered pain medication"
C. "Incision without redness or drainage"
D. "Drank adequate amounts of fluid with meals"
, Correct Answer: B. "Administered pain medication"
Rationale: Documentation should be objective, specific, and factual. "Administered pain
medication" is a clear, factual statement. The other options are vague and use subjective terms
like "slightly," "without," and "adequate" that do not provide measurable data .
9. A nurse is caring for a client who has a terminal illness and decides to discontinue active
treatment. What is the most appropriate therapeutic response from the nurse?
A. "Why are you choosing to give up now?"
B. "Tell me more about your decision and what led you to this choice"
C. "What does your family think about this decision?"
D. "There are still other treatment options you could consider"
Correct Answer: B. "Tell me more about your decision and what led you to this choice"
Rationale: This open-ended, nonjudgmental response invites the client to express their
thoughts and feelings while demonstrating respect for patient autonomy. It avoids value
judgments and respects patient-centered care principles .
10. A nurse is providing discharge teaching to a client who does not speak the same language
as the nurse. Which of the following actions should the nurse take?
A. Direct verbal discharge instructions to the interpreter
B. Use hand gestures and drawings to communicate
C. Ask a family member to interpret the instructions
D. Provide written instructions in the client's language only
Correct Answer: A. Direct verbal discharge instructions to the interpreter
Rationale: When using an interpreter, the nurse should direct communication to the client,
not the interpreter. Family members should not be used as interpreters due to confidentiality
and potential for misinterpretation. Written instructions alone are insufficient without verbal
teaching .
11. A nurse is caring for a client who has bilateral casts on her hands. Which action should the
nurse take when assisting the client with feeding?
A. Sit at the bedside while feeding the client
B. Feed the client quickly to prevent fatigue
