Questions & Answers, ATI RN Fundamentals Exam Prep, Nursing
Skills and Procedures, Patient Safety, Infection Control, Clinical
Judgment, Basic Care, and Detailed Rationales
Question 1: A nurse is preparing to administer a medication to a client.
Which of the following actions should the nurse take first?
A. Check the client's identification band
B. Verify the medication order
C. Assess the client's vital signs
D. Administer the medication
CORRECT ANSWER: B. Verify the medication order
Rationale: The first step in the medication administration process is
verifying the medication order to ensure it is complete, legible, and
appropriate for the client. This precedes checking the client's
identification, assessing vital signs, or administering the medication.
Question 2: A nurse is caring for a client who has a prescription for bed
rest. Which of the following complications should the nurse monitor
for?
A. Increased muscle tone
B. Decreased risk of blood clots
C. Muscle atrophy
D. Improved respiratory function
CORRECT ANSWER: C. Muscle atrophy
Rationale: Prolonged bed rest leads to muscle atrophy due to disuse.
Immobility also increases the risk of blood clots, respiratory complications,
and decreased muscle tone, making muscle atrophy the correct
complication to monitor.
Question 3: A nurse is performing a focused assessment on a client
who reports difficulty breathing. Which of the following findings should
the nurse prioritize?
A. Respiratory rate of 18/min
B. Oxygen saturation of 89%
C. Blood pressure of 120/80 mm Hg
D. Heart rate of 88/min
,CORRECT ANSWER: B. Oxygen saturation of 89%
Rationale: An oxygen saturation below 90% indicates hypoxemia and
requires immediate intervention. The other vital signs are within normal
limits and do not require immediate prioritization.
Question 4: A nurse is teaching a client about proper hand hygiene.
Which of the following statements by the client indicates
understanding?
A. "I should wash my hands for at least 5 seconds."
B. "I should use alcohol-based hand rub when my hands are visibly soiled."
C. "I should wash my hands for at least 20 seconds with soap and water."
D. "I only need to wash my hands after using the restroom."
CORRECT ANSWER: C. "I should wash my hands for at least 20 seconds
with soap and water."
Rationale: Proper hand hygiene requires washing with soap and water for at
least 20 seconds. Alcohol-based hand rub is not effective when hands are
visibly soiled, and hand hygiene should be performed at multiple points
during client care.
Question 5: A nurse is assessing a client for signs of dehydration.
Which of the following findings should the nurse expect?
A. Bounding pulse
B. Moist mucous membranes
C. Poor skin turgor
D. Increased urine output
CORRECT ANSWER: C. Poor skin turgor
Rationale: Poor skin turgor is a classic sign of dehydration due to
decreased interstitial fluid. Bounding pulse, moist mucous membranes,
and increased urine output are inconsistent with dehydration.
Question 6: A nurse is preparing to move a client up in bed. Which of
the following actions should the nurse take to prevent injury?
A. Keep the bed at a low position
B. Use a draw sheet and raise the bed to a comfortable working height
C. Twist the torso while pulling the client
D. Avoid using assistive devices
,CORRECT ANSWER: B. Use a draw sheet and raise the bed to a
comfortable working height
Rationale: Using a draw sheet and raising the bed to a comfortable working
height promotes proper body mechanics and reduces the risk of
musculoskeletal injury to the nurse. Twisting the torso and keeping the bed
low increase injury risk.
Question 7: A nurse is caring for a client who is at risk for falls. Which of
the following interventions should the nurse implement?
A. Keep the bed in the highest position
B. Apply a bed alarm
C. Leave the side rails down
D. Encourage the client to walk without assistance
CORRECT ANSWER: B. Apply a bed alarm
Rationale: A bed alarm alerts staff when a high-risk client attempts to get
up without assistance, reducing fall risk. Keeping the bed high, leaving side
rails down, and encouraging unassisted walking increase fall risk.
Question 8: A nurse is documenting a client's intake and output. Which
of the following should the nurse record as intake?
A. Urine output
B. Emesis
C. Ice chips
D. Wound drainage
CORRECT ANSWER: C. Ice chips
Rationale: Ice chips are considered oral intake and should be recorded,
typically as half the volume of the ice chips. Urine output, emesis, and
wound drainage are recorded as output.
Question 9: A nurse is assessing a client's pain level. Which of the
following tools is most appropriate for a client who is nonverbal?
A. Numeric rating scale
B. Wong-Baker FACES scale
C. Visual analog scale
D. Verbal descriptor scale
, CORRECT ANSWER: B. Wong-Baker FACES scale
Rationale: The Wong-Baker FACES scale uses facial expressions to assess
pain and is appropriate for clients who are nonverbal or have difficulty
communicating verbally. The other scales require verbal or numeric
communication.
Question 10: A nurse is preparing to administer an enema to a client.
Which of the following positions should the nurse place the client in?
A. Supine
B. Left lateral Sims' position
C. Prone
D. High Fowler's
CORRECT ANSWER: B. Left lateral Sims' position
Rationale: The left lateral Sims' position allows gravity to assist the flow of
the enema solution into the colon. Supine, prone, and High Fowler's
positions are not appropriate for enema administration.
Question 11: A nurse is caring for a client who has a new prescription
for a potassium-sparing diuretic. Which of the following foods should
the nurse instruct the client to avoid?
A. Bananas
B. Oranges
C. Salt substitutes
D. Potatoes
CORRECT ANSWER: C. Salt substitutes
Rationale: Salt substitutes often contain potassium, and combining them
with a potassium-sparing diuretic can lead to hyperkalemia. Bananas,
oranges, and potatoes are also high in potassium but are not typically
restricted unless potassium levels are elevated.
Question 12: A nurse is performing a sterile dressing change. Which of
the following actions indicates a break in sterile technique?
A. Opening the sterile package away from the body
B. Placing sterile supplies on the sterile field
C. Reaching over the sterile field with a non-sterile arm
D. Using sterile gloves to handle sterile supplies