RATIONALES 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
A nurse in an acute care facility is preparing a discharge summary
for a client who is transferring to a long-term care facility. Which of
the following documentation should the nurse include? C. Current medications
A. Client flow sheet The nurse should include the client's medications in the discharge
B. Acuity ratings summary to ensure client safety and continuity of care.
C. Current medications
D. Incident reports
A nurse is reviewing protocol in preparation for suctioning secre-
tions from a client who has a new tracheostomy. Which of the
following actions should the nurse plan to take? B. Select a suction catheter that is half the size of the lumen.
A. Use a resuscitation bag with 80% oxygen prior to the procedure. The nurse should select a suction catheter that is half the size of
B. Select a suction catheter that is half the size of the lumen. the lumen to prevent hypoxemia and trauma to the mucosa.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.
A nurse is caring for a client who has decreased mobility. Which of
the following actions should the nurse take to decrease the client's D. Apply an ankle-foot orthotic device to the client's feet.
risk of developing plantar flexion contractures?
The nurse should use a device to maintain dorsiflexion, such as
A. Place a pillow under the client's knees.
an ankle-foot orthotic device or a foot board placed perpendicular
B. Position a trochanter roll under each of the client's hips.
to the mattress.
C. Advise the client to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the client's feet.
A nurse manager is overseeing the care activities on a unit.
For which of the following situations should the nurse manager
intervene due to a violation of HIPAA guidelines?
B. A nurse asks a nurse from another unit to assist with documen-
A. A nurse who is caring for a client reviews the client's medical tation for a client.
chart with a nursing student who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documen- Only health care professionals directly caring for a client should
tation for a client. have access to the client's medical information; therefore, this is a
C. A nurse who is caring for a client returns a call to the person violation of HIPAA guidelines.
appointed in the health care proxy to discuss the client's care.
D. A nurse discusses a client's status with the physical therapist
who is caring for the client.
A nurse is preparing to administer 0.5 mL of oral single-dose liquid
medication to a client. Which of the following actions should the
nurse take?
A. Gently shake the container of medication prior to administration.
A. Gently shake the container of medication prior to administra-
tion.
The nurse should gently shake the liquid medication to ensure that
B. Transfer the medication to a medicine cup.
the medication is mixed.
C. Place the client in a semi-Fowler's position prior to medication
administration.
D. Verify the dosage by measuring the liquid before administering
it.
A nurse on a medical unit is preparing to discharge a client to
D. Compare prescriptions with medications the client received
home. Which of the following actions should the nurse take as part
while at the facility.
of the medication reconciliation process?
When performing medication reconciliation, the nurse should cre-
A. Seal unused medications from the facility in a plastic bag.
ate a current, accurate list of every medication the client is or
B. Evaluate the client's ability to self-administer medications.
should be taking. Part of the process is comparing the medica-
C. Report an identified discrepancy to The Joint Commission.
tions the client received at the facility with those the provider has
D. Compare prescriptions with medications the client received
prescribed for the client to take after discharge.
while at the facility.
A nurse is caring for a client who has terminal liver cancer. Which
of the following statements should the nurse identify as an indi-
, ATI RN FUNDAMENTAL PROCTORED ACTUAL EXAM QUESTIONS AND ANSWERS WITH
RATIONALES 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
cation that the client is experiencing spiritual distress?
A. "What could I have done to deserve this illness?"
A. "What could I have done to deserve this illness?"
The client's terminal illness might prompt the client to review
B. "I blame medical science for not curing me."
their life and question its meaning. A manifestation of the client's
C. "Where is my daughter at a time like this?"
spiritual distress is asking why this illness is happening to them.
D. "Will I ever begin to feel in charge of my life again?"
C. Inject 10 units of air into the bottle of NPH insulin.
A nurse is caring for a client who has a prescription for 5 units A. Inject 5 units of air into the bottle of regular insulin.
of regular insulin and 10 units of NPH insulin to mix together D. Withdraw the correct does of regular insulin from the bottle.
and administer subcutaneously. Determine the correct order of B. Withdraw the correct does of NPH insulin from the bottle.
steps for this procedure. (Move the steps into the box on the right,
placing them in the order of performance. Use all the steps.) The nurse should first inject air into the vial of NPH insulin without
touching the needle to the solution. Next, the nurse should inject
A. Inject 5 units of air into the bottle of regular insulin. air into the vial of regular insulin and withdraw the correct amount
B. Withdraw the correct does of NPH insulin from the bottle. of the regular insulin. Finally, the nurse should insert the needle
C. Inject 10 units of air into the bottle of NPH insulin. into the NPH insulin vial and withdraw the correct amount of NPH
D. Withdraw the correct does of regular insulin from the bottle. insulin. The nurse should follow these steps to prevent contami-
nating the regular insulin with NPH insulin.
A nurse is completing an admission assessment for a client who
reports vomiting and diarrhea for the past 3 days. Which of the
following findings should the nurse expect? C. Rapid heart rate
A. Neck vein distention Tachycardia indicates fluid volume deficit, which is an expected
B. Urine specific gravity 1.010 finding for a client who has had vomiting and diarrhea for 3 days.
C. Rapid heart rate
D. Blood pressure 144/82 mm Hg
C. Assess the client for orthostatic hypotension.
A nurse is preparing to transfer a client who can bear weight on
one leg from the bed to a chair. After securing a safe environment,
The first action the nurse should take when using the nursing
which of the following actions should the nurse take next?
process is to assess the client. The nurse should determine the
client's risk for falling or fainting during the transfer by assisting
A. Rock the client up to a standing position.
the client to sit and dangle the feet on the side of the bed. The
B. Pivot on the foot that is the farthest from the chair.
nurse should assess for dizziness and a significant drop in blood
C. Assess the client for orthostatic hypotension.
pressure before assisting the client to stand and transfer into the
D. Apply a gait belt to the client.
chair.
A nurse is admitting a client who reports experiencing a sore
throat, productive cough, and fever for the past 3 days.
A. Request a prescription for an antibiotic medication.
The nurse should identify that the client has streptococcal pharyn-
The nurse is reviewing the client's medical record. Which of the
gitis due to the client's manifestations and a positive throat culture.
following actions should the nurse take?
Therefore, the nurse should request an antibiotic medication, such
Select all that apply.
as penicillin, to treat the client's infection.
Nurses' Notes
C. Initiate droplet precautions.
1000:
The nurse should identify that the client has streptococcal pharyn-
Client reports sore throat, productive cough with yellow-colored
gitis, which is transmitted through droplets greater than 5 microns
mucus, and fever for the past 3 days. Client has swollen lymph
in the air. Therefore, the nurse should initiate droplet precautions
nodes. Client also reports headache that, "won't go away." Client's for the client.
face is flushed and diaphoretic. Throat culture and blood work
obtained as prescribed.
D. Wear a mask within 1 m (3 feet) of the client.
The nurse should identify that the client has streptococcal pharyn-
Vital Signs
gitis. Therefore, the nurse should wear a mask when within 1 m (3
1000:
feet) of the client to prevent the spread of the infection.
Blood pressure 132/68 mm Hg, Heart rate 99/min, Respiratory
rate 20/min, Temperature 38.3° C (101° F), Oxygen saturation
F. Apply a mask on the client when they leave their room.
96% on room air
The nurse should identify that the client has streptococcal pharyn-
Diagnostic Results
1100: