ATI & NCLEX Review/Test 1: 200 Multiple Choice
Questions with Verified Answers and Detailed
Rationales for Comprehensive Practice Exam Study
Guide 2026/2027
SECTION 1: FUNDAMENTALS OF NURSING (Questions 1–35)
Question 1
A nurse is performing an admission assessment for a client who appears
withdrawn and fearful. Which action should the nurse take first?
A) Ask the client directly about the source of their fear
B) Sit quietly with the client to establish trust
C) Begin the physical assessment immediately
D) Request that the client's family leave the room
ANS: B
Rationale: A withdrawn, fearful client may feel overwhelmed by direct
questioning. Sitting quietly demonstrates acceptance and allows the client to set
the pace. Trust must be established before assessment can proceed effectively.
Question 2
A nurse is assessing a client's level of consciousness. Which finding indicates the
highest level of alertness?
,A) Responds to voice
B) Responds to pain
C) Alert and oriented
D) Unresponsive
ANS: C
Rationale: Alert and oriented indicates the highest level of consciousness.
Responses to voice, pain, or unresponsiveness indicate progressively decreased
levels of consciousness.
Question 3
Which finding is an early sign of increased intracranial pressure (ICP)?
A) Cushing triad
B) Decreased level of consciousness
C) Papilledema
D) Irregular respirations
ANS: B
Rationale: Decreased level of consciousness is an early sign of increased ICP.
Cushing triad and papilledema are late signs.
Question 4
A nurse is caring for a client with a new colostomy. Which finding should the nurse
report to the provider?
,A) Stoma is pink and moist
B) Stoma is dark and dusky
C) Small amount of bleeding at the stoma
D) Output is liquid initially
ANS: B
Rationale: A dark, dusky stoma indicates inadequate blood supply and possible
necrosis, which requires immediate provider notification.
Question 5
A nurse is preparing to administer an intramuscular injection. Which site is
preferred for adults?
A) Deltoid
B) Ventrogluteal
C) Dorsogluteal
D) Vastus lateralis
ANS: B
Rationale: The ventrogluteal site is preferred for IM injections in adults because it
is free of major nerves and blood vessels.
Question 6
A client is prescribed a clear liquid diet. Which item should the nurse include on
the tray?
, A) Cream of chicken soup
B) Orange gelatin
C) Vanilla ice cream
D) Whole milk
ANS: B
Rationale: Clear liquids are transparent at room temperature. Orange gelatin is a
clear liquid. Cream soups, ice cream, and milk are full liquids.
Question 7
A nurse is teaching a client about using an incentive spirometer. Which instruction
should the nurse include?
A) "Exhale forcefully into the device."
B) "Inhale slowly and deeply to raise the indicator."
C) "Use the device only when you feel short of breath."
D) "Hold your breath for 1 second after inhaling."
ANS: B
Rationale: The incentive spirometer encourages deep inhalation to prevent
atelectasis. The client should inhale slowly and deeply to raise the indicator.
Question 8
A nurse is caring for a client with a surgical wound. Which finding indicates
infection?
Questions with Verified Answers and Detailed
Rationales for Comprehensive Practice Exam Study
Guide 2026/2027
SECTION 1: FUNDAMENTALS OF NURSING (Questions 1–35)
Question 1
A nurse is performing an admission assessment for a client who appears
withdrawn and fearful. Which action should the nurse take first?
A) Ask the client directly about the source of their fear
B) Sit quietly with the client to establish trust
C) Begin the physical assessment immediately
D) Request that the client's family leave the room
ANS: B
Rationale: A withdrawn, fearful client may feel overwhelmed by direct
questioning. Sitting quietly demonstrates acceptance and allows the client to set
the pace. Trust must be established before assessment can proceed effectively.
Question 2
A nurse is assessing a client's level of consciousness. Which finding indicates the
highest level of alertness?
,A) Responds to voice
B) Responds to pain
C) Alert and oriented
D) Unresponsive
ANS: C
Rationale: Alert and oriented indicates the highest level of consciousness.
Responses to voice, pain, or unresponsiveness indicate progressively decreased
levels of consciousness.
Question 3
Which finding is an early sign of increased intracranial pressure (ICP)?
A) Cushing triad
B) Decreased level of consciousness
C) Papilledema
D) Irregular respirations
ANS: B
Rationale: Decreased level of consciousness is an early sign of increased ICP.
Cushing triad and papilledema are late signs.
Question 4
A nurse is caring for a client with a new colostomy. Which finding should the nurse
report to the provider?
,A) Stoma is pink and moist
B) Stoma is dark and dusky
C) Small amount of bleeding at the stoma
D) Output is liquid initially
ANS: B
Rationale: A dark, dusky stoma indicates inadequate blood supply and possible
necrosis, which requires immediate provider notification.
Question 5
A nurse is preparing to administer an intramuscular injection. Which site is
preferred for adults?
A) Deltoid
B) Ventrogluteal
C) Dorsogluteal
D) Vastus lateralis
ANS: B
Rationale: The ventrogluteal site is preferred for IM injections in adults because it
is free of major nerves and blood vessels.
Question 6
A client is prescribed a clear liquid diet. Which item should the nurse include on
the tray?
, A) Cream of chicken soup
B) Orange gelatin
C) Vanilla ice cream
D) Whole milk
ANS: B
Rationale: Clear liquids are transparent at room temperature. Orange gelatin is a
clear liquid. Cream soups, ice cream, and milk are full liquids.
Question 7
A nurse is teaching a client about using an incentive spirometer. Which instruction
should the nurse include?
A) "Exhale forcefully into the device."
B) "Inhale slowly and deeply to raise the indicator."
C) "Use the device only when you feel short of breath."
D) "Hold your breath for 1 second after inhaling."
ANS: B
Rationale: The incentive spirometer encourages deep inhalation to prevent
atelectasis. The client should inhale slowly and deeply to raise the indicator.
Question 8
A nurse is caring for a client with a surgical wound. Which finding indicates
infection?
