NR 224: ATI Fundamentals Proctored Exam Prep with Detailed Rationales
Course Code: NR 224
Course Name: Fundamentals of Nursing
Topic: Comprehensive Nursing Care, Safety, & Pharmacology
Academic Year: 2026/2027
1. A nurse is planning care for a group of clients. Which of the following tasks
should 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
CORRECT ANSWER: D
RATIONALE: Postmortem care consists of non-invasive, standard hygiene
procedures that do not require clinical assessment or judgment, making it safe to
delegate to an AP. In contrast, changing dressings for a complex stage 3 pressure
injury, evaluating responses to medications (like diuretics), and assessing radial
pulses postoperatively all demand the specialized clinical reasoning, judgment, and
advanced evaluation skills of a licensed nurse.
2. A nurse is conducting a health assessment for a client who takes herbal
supplements. Which of the following statements by the client indicates an
understanding of the use of the supplements?
A. "I take ginkgo biloba for a headache."
B. "I take echinacea to control my cholesterol."
C. "I use ginger when I get car sick."
D. "I use garlic for my menopausal symptoms."
CORRECT ANSWER: C
RATIONALE: Ginger is widely recognized and clinically supported for its
antiemetic properties, making it highly effective for treating motion sickness (car
sickness), nausea, and vomiting. Other supplements are misused in the options:
ginkgo biloba is traditionally utilized to enhance memory and cognitive function
rather than treat acute headaches; echinacea serves as an immune stimulant to
prevent or reduce the duration of the common cold instead of managing
,cholesterol; and garlic is primarily used to lower blood pressure and cholesterol,
not to alleviate menopausal symptoms.
3. A nurse is caring for a client who has influenza and isolation precautions in
place. 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
CORRECT ANSWER: A
RATIONALE: Influenza is transmitted via large respiratory droplets, which
requires standard droplet precautions. A nurse must wear a mask when operating
within a 3-foot radius of the client to block droplet transmission. Metronidazole is
an antimicrobial targeting anaerobic bacteria and protozoa, not viruses like
influenza. Protective eyewear is only mandatory during splash-producing
procedures, and negative airflow rooms are reserved for airborne infections such as
tuberculosis.
4. 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
CORRECT ANSWER: C
RATIONALE: Safety guidelines mandate leaving enough space to allow two
fingers to fit between the restraint and the client's skin to preserve neurovascular
integrity and prevent tissue injury. Restraints must always be secured to the
movable bed frame, never to the side rails, to prevent injury when the head or foot
of the bed is adjusted. Restraints should permit a safe degree of movement rather
than restricting it entirely, and they must be removed for assessment and range of
motion at least every 2 hours, making a 4-hour interval unsafe.
5. 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
CORRECT ANSWER: B
RATIONALE: Mycobacterium tuberculosis is transmitted via microscopic
droplet nuclei that remain suspended in the air for long periods, requiring strict
airborne precautions. This protocol demands a negative-pressure isolation room
and an N95 respirator mask for healthcare staff. Droplet precautions are for larger
particles (e.g., influenza); contact precautions target direct or indirect surface touch
transmission (e.g., MRSA, C. difficile); and a protective environment is a positive-
pressure room reserved for severely immunocompromised patients, such as stem
cell transplant recipients.
6. A nurse in a well-child clinic receives a telephone call from a parent who states
that their child accidentally swallowed paint thinner. The child is awake and alert.
Which of the following responses should the nurse make?
A. "Have your child drink one large glass of water."
B. "Hang up and call a poison control center hotline."
C. "Bring your child into the clinic later today."
D. "Induce vomiting in your child with syrup of ipecac."
CORRECT ANSWER: A
RATIONALE: For an awake and alert child who has ingested a chemical like
paint thinner, immediate dilution with a glass of water helps minimize mucosal
irritation before emergency medical intervention. Telling the parent to hang up or
delaying evaluation until "later today" introduces unsafe delays in care. Inducing
vomiting using syrup of ipecac is strictly contraindicated because re-exposure to
caustic or hydrocarbon substances can severely burn the esophagus and cause life-
threatening aspiration pneumonia.
7. A nurse is documenting 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"
Course Code: NR 224
Course Name: Fundamentals of Nursing
Topic: Comprehensive Nursing Care, Safety, & Pharmacology
Academic Year: 2026/2027
1. A nurse is planning care for a group of clients. Which of the following tasks
should 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
CORRECT ANSWER: D
RATIONALE: Postmortem care consists of non-invasive, standard hygiene
procedures that do not require clinical assessment or judgment, making it safe to
delegate to an AP. In contrast, changing dressings for a complex stage 3 pressure
injury, evaluating responses to medications (like diuretics), and assessing radial
pulses postoperatively all demand the specialized clinical reasoning, judgment, and
advanced evaluation skills of a licensed nurse.
2. A nurse is conducting a health assessment for a client who takes herbal
supplements. Which of the following statements by the client indicates an
understanding of the use of the supplements?
A. "I take ginkgo biloba for a headache."
B. "I take echinacea to control my cholesterol."
C. "I use ginger when I get car sick."
D. "I use garlic for my menopausal symptoms."
CORRECT ANSWER: C
RATIONALE: Ginger is widely recognized and clinically supported for its
antiemetic properties, making it highly effective for treating motion sickness (car
sickness), nausea, and vomiting. Other supplements are misused in the options:
ginkgo biloba is traditionally utilized to enhance memory and cognitive function
rather than treat acute headaches; echinacea serves as an immune stimulant to
prevent or reduce the duration of the common cold instead of managing
,cholesterol; and garlic is primarily used to lower blood pressure and cholesterol,
not to alleviate menopausal symptoms.
3. A nurse is caring for a client who has influenza and isolation precautions in
place. 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
CORRECT ANSWER: A
RATIONALE: Influenza is transmitted via large respiratory droplets, which
requires standard droplet precautions. A nurse must wear a mask when operating
within a 3-foot radius of the client to block droplet transmission. Metronidazole is
an antimicrobial targeting anaerobic bacteria and protozoa, not viruses like
influenza. Protective eyewear is only mandatory during splash-producing
procedures, and negative airflow rooms are reserved for airborne infections such as
tuberculosis.
4. 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
CORRECT ANSWER: C
RATIONALE: Safety guidelines mandate leaving enough space to allow two
fingers to fit between the restraint and the client's skin to preserve neurovascular
integrity and prevent tissue injury. Restraints must always be secured to the
movable bed frame, never to the side rails, to prevent injury when the head or foot
of the bed is adjusted. Restraints should permit a safe degree of movement rather
than restricting it entirely, and they must be removed for assessment and range of
motion at least every 2 hours, making a 4-hour interval unsafe.
5. 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
CORRECT ANSWER: B
RATIONALE: Mycobacterium tuberculosis is transmitted via microscopic
droplet nuclei that remain suspended in the air for long periods, requiring strict
airborne precautions. This protocol demands a negative-pressure isolation room
and an N95 respirator mask for healthcare staff. Droplet precautions are for larger
particles (e.g., influenza); contact precautions target direct or indirect surface touch
transmission (e.g., MRSA, C. difficile); and a protective environment is a positive-
pressure room reserved for severely immunocompromised patients, such as stem
cell transplant recipients.
6. A nurse in a well-child clinic receives a telephone call from a parent who states
that their child accidentally swallowed paint thinner. The child is awake and alert.
Which of the following responses should the nurse make?
A. "Have your child drink one large glass of water."
B. "Hang up and call a poison control center hotline."
C. "Bring your child into the clinic later today."
D. "Induce vomiting in your child with syrup of ipecac."
CORRECT ANSWER: A
RATIONALE: For an awake and alert child who has ingested a chemical like
paint thinner, immediate dilution with a glass of water helps minimize mucosal
irritation before emergency medical intervention. Telling the parent to hang up or
delaying evaluation until "later today" introduces unsafe delays in care. Inducing
vomiting using syrup of ipecac is strictly contraindicated because re-exposure to
caustic or hydrocarbon substances can severely burn the esophagus and cause life-
threatening aspiration pneumonia.
7. A nurse is documenting 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"
