ATI Fundamentals CMS Proctored
Exam 2025 Actual – 100+ Verified
Test Bank Questions with Correct
Answers | Graded A+
Question 1
A nurse is assessing a client with chest pain that worsens with inspiration. The nurse auscultates
a high-pitched scratching sound during both systole and diastole at the left sternal border. Which
heart sound should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D
Rationale:
A. Audible click: Incorrect. An audible click is typically associated with mechanical heart
valves, not chest pain worsened by inspiration.
B. Murmur: Incorrect. A murmur is a blowing or whooshing sound caused by turbulent
blood flow, often due to valve dysfunction, not matching the high-pitched scratching
described.
C. Third heart sound: Incorrect. A third heart sound (S3) is a low-pitched sound associated
with heart failure or fluid overload, not a scratching sound.
D. Pericardial friction rub: Correct. A high-pitched scratching sound heard during systole
and diastole at the left sternal border is characteristic of a pericardial friction rub, often
associated with pericarditis, which causes chest pain worsened by inspiration.
Question 2
A nurse is obtaining a client’s blood pressure in the lower extremity. Which action should the
nurse take?
A. Auscultate the blood pressure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6 cm (3 in) above the popliteal artery.
D. Place the bladder of the cuff over the posterior aspect of the thigh.
,Correct Answer: D
Rationale:
A. Auscultate the blood pressure at the dorsalis pedis artery: Incorrect. The dorsalis pedis
artery is used for pulse assessment, not blood pressure auscultation. The popliteal artery
is used for lower extremity blood pressure.
B. Measure the blood pressure with the client sitting on the side of the bed: Incorrect.
Lower extremity blood pressure is typically measured with the client lying prone or
supine to access the popliteal artery.
C. Place the cuff 7.6 cm (3 in) above the popliteal artery: Incorrect. The cuff should be
placed directly over the popliteal artery, not 3 inches above it, to ensure accurate
measurement.
D. Place the bladder of the cuff over the posterior aspect of the thigh: Correct. The
bladder of the cuff must be centered over the popliteal artery on the posterior thigh for an
accurate lower extremity blood pressure reading.
Question 3
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to newly licensed nurses.
Which action should the charge nurse teach as the first response in CPR?
A. Call for help or activate the emergency response system.
B. Check for a pulse.
C. Begin chest compressions.
D. Open the airway.
Correct Answer: A
Rationale:
A. Call for help or activate the emergency response system: Correct. The first step in CPR
for an unresponsive adult is to assess responsiveness and, if unresponsive, call for help or
activate the emergency response system to ensure timely assistance.
B. Check for a pulse: Incorrect. Pulse checking follows calling for help and is part of
assessing circulation after ensuring help is on the way.
C. Begin chest compressions: Incorrect. Compressions start after confirming
unresponsiveness and activating emergency response, per AHA guidelines.
D. Open the airway: Incorrect. Opening the airway occurs after calling for help and
assessing breathing, not as the first step.
Question 4
,A nurse is reinforcing teaching with a client about collecting a stool specimen for ova and
parasites. Which instruction should the nurse include?
A. Place toilet tissue in the bedpan after defecation.
B. Collect the specimen in a clean, dry container.
C. Refrigerate the specimen immediately after collection.
D. Collect the specimen after taking antibiotics.
Correct Answer: B
Rationale:
A. Place toilet tissue in the bedpan after defecation: Incorrect. Toilet tissue can
contaminate the specimen, interfering with accurate testing for ova and parasites.
B. Collect the specimen in a clean, dry container: Correct. A clean, dry container is
required to prevent contamination and ensure accurate test results.
C. Refrigerate the specimen immediately after collection: Incorrect. While some
specimens require refrigeration, ova and parasite specimens should be kept at room
temperature and delivered promptly to the lab.
D. Collect the specimen after taking antibiotics: Incorrect. Antibiotics can alter the
presence of parasites, leading to false-negative results.
Question 5
A nurse is preparing to administer an intramuscular injection. Which action should the nurse
perform first?
A. Select the appropriate needle size.
B. Wash their hands.
C. Identify the correct injection site.
D. Don gloves.
Correct Answer: B
Rationale:
A. Select the appropriate needle size: Incorrect. While important, selecting the needle size
follows hand hygiene to ensure infection control.
B. Wash their hands: Correct. Hand hygiene is the first step in any procedure to prevent
infection and maintain patient safety.
C. Identify the correct injection site: Incorrect. Site identification occurs after hand hygiene
to maintain a sterile process.
D. Don gloves: Incorrect. Gloves are donned after hand hygiene and before handling sterile
equipment.
, Question 6
A nurse is caring for a client receiving a blood transfusion. Which action is most important
during the first 15 minutes of the transfusion?
A. Monitor vital signs every 15 minutes.
B. Observe for signs of a transfusion reaction.
C. Administer the transfusion at a rapid rate.
D. Ask the client if they feel uncomfortable.
Correct Answer: B
Rationale:
A. Monitor vital signs every 15 minutes: Incorrect. While monitoring vital signs is
important, it is not the priority during the first 15 minutes compared to observing for
transfusion reactions.
B. Observe for signs of a transfusion reaction: Correct. The first 15 minutes are critical for
detecting acute transfusion reactions, such as hemolytic or allergic reactions, which
require immediate intervention.
C. Administer the transfusion at a rapid rate: Incorrect. Transfusions should start slowly
to minimize reaction risks.
D. Ask the client if they feel uncomfortable: Incorrect. While assessing patient comfort is
important, it is less specific than observing for objective signs of a transfusion reaction.
Question 7
A nurse is assessing a client for signs of dehydration. Which finding is most indicative of
dehydration?
A. Bradycardia
B. Dry mucous membranes
C. Diaphoresis
D. Increased urine output
Correct Answer: B
Rationale:
A. Bradycardia: Incorrect. Dehydration typically causes tachycardia due to decreased blood
volume, not bradycardia.
B. Dry mucous membranes: Correct. Dry mucous membranes are a hallmark sign of
dehydration due to reduced fluid availability in tissues.
Exam 2025 Actual – 100+ Verified
Test Bank Questions with Correct
Answers | Graded A+
Question 1
A nurse is assessing a client with chest pain that worsens with inspiration. The nurse auscultates
a high-pitched scratching sound during both systole and diastole at the left sternal border. Which
heart sound should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D
Rationale:
A. Audible click: Incorrect. An audible click is typically associated with mechanical heart
valves, not chest pain worsened by inspiration.
B. Murmur: Incorrect. A murmur is a blowing or whooshing sound caused by turbulent
blood flow, often due to valve dysfunction, not matching the high-pitched scratching
described.
C. Third heart sound: Incorrect. A third heart sound (S3) is a low-pitched sound associated
with heart failure or fluid overload, not a scratching sound.
D. Pericardial friction rub: Correct. A high-pitched scratching sound heard during systole
and diastole at the left sternal border is characteristic of a pericardial friction rub, often
associated with pericarditis, which causes chest pain worsened by inspiration.
Question 2
A nurse is obtaining a client’s blood pressure in the lower extremity. Which action should the
nurse take?
A. Auscultate the blood pressure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6 cm (3 in) above the popliteal artery.
D. Place the bladder of the cuff over the posterior aspect of the thigh.
,Correct Answer: D
Rationale:
A. Auscultate the blood pressure at the dorsalis pedis artery: Incorrect. The dorsalis pedis
artery is used for pulse assessment, not blood pressure auscultation. The popliteal artery
is used for lower extremity blood pressure.
B. Measure the blood pressure with the client sitting on the side of the bed: Incorrect.
Lower extremity blood pressure is typically measured with the client lying prone or
supine to access the popliteal artery.
C. Place the cuff 7.6 cm (3 in) above the popliteal artery: Incorrect. The cuff should be
placed directly over the popliteal artery, not 3 inches above it, to ensure accurate
measurement.
D. Place the bladder of the cuff over the posterior aspect of the thigh: Correct. The
bladder of the cuff must be centered over the popliteal artery on the posterior thigh for an
accurate lower extremity blood pressure reading.
Question 3
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to newly licensed nurses.
Which action should the charge nurse teach as the first response in CPR?
A. Call for help or activate the emergency response system.
B. Check for a pulse.
C. Begin chest compressions.
D. Open the airway.
Correct Answer: A
Rationale:
A. Call for help or activate the emergency response system: Correct. The first step in CPR
for an unresponsive adult is to assess responsiveness and, if unresponsive, call for help or
activate the emergency response system to ensure timely assistance.
B. Check for a pulse: Incorrect. Pulse checking follows calling for help and is part of
assessing circulation after ensuring help is on the way.
C. Begin chest compressions: Incorrect. Compressions start after confirming
unresponsiveness and activating emergency response, per AHA guidelines.
D. Open the airway: Incorrect. Opening the airway occurs after calling for help and
assessing breathing, not as the first step.
Question 4
,A nurse is reinforcing teaching with a client about collecting a stool specimen for ova and
parasites. Which instruction should the nurse include?
A. Place toilet tissue in the bedpan after defecation.
B. Collect the specimen in a clean, dry container.
C. Refrigerate the specimen immediately after collection.
D. Collect the specimen after taking antibiotics.
Correct Answer: B
Rationale:
A. Place toilet tissue in the bedpan after defecation: Incorrect. Toilet tissue can
contaminate the specimen, interfering with accurate testing for ova and parasites.
B. Collect the specimen in a clean, dry container: Correct. A clean, dry container is
required to prevent contamination and ensure accurate test results.
C. Refrigerate the specimen immediately after collection: Incorrect. While some
specimens require refrigeration, ova and parasite specimens should be kept at room
temperature and delivered promptly to the lab.
D. Collect the specimen after taking antibiotics: Incorrect. Antibiotics can alter the
presence of parasites, leading to false-negative results.
Question 5
A nurse is preparing to administer an intramuscular injection. Which action should the nurse
perform first?
A. Select the appropriate needle size.
B. Wash their hands.
C. Identify the correct injection site.
D. Don gloves.
Correct Answer: B
Rationale:
A. Select the appropriate needle size: Incorrect. While important, selecting the needle size
follows hand hygiene to ensure infection control.
B. Wash their hands: Correct. Hand hygiene is the first step in any procedure to prevent
infection and maintain patient safety.
C. Identify the correct injection site: Incorrect. Site identification occurs after hand hygiene
to maintain a sterile process.
D. Don gloves: Incorrect. Gloves are donned after hand hygiene and before handling sterile
equipment.
, Question 6
A nurse is caring for a client receiving a blood transfusion. Which action is most important
during the first 15 minutes of the transfusion?
A. Monitor vital signs every 15 minutes.
B. Observe for signs of a transfusion reaction.
C. Administer the transfusion at a rapid rate.
D. Ask the client if they feel uncomfortable.
Correct Answer: B
Rationale:
A. Monitor vital signs every 15 minutes: Incorrect. While monitoring vital signs is
important, it is not the priority during the first 15 minutes compared to observing for
transfusion reactions.
B. Observe for signs of a transfusion reaction: Correct. The first 15 minutes are critical for
detecting acute transfusion reactions, such as hemolytic or allergic reactions, which
require immediate intervention.
C. Administer the transfusion at a rapid rate: Incorrect. Transfusions should start slowly
to minimize reaction risks.
D. Ask the client if they feel uncomfortable: Incorrect. While assessing patient comfort is
important, it is less specific than observing for objective signs of a transfusion reaction.
Question 7
A nurse is assessing a client for signs of dehydration. Which finding is most indicative of
dehydration?
A. Bradycardia
B. Dry mucous membranes
C. Diaphoresis
D. Increased urine output
Correct Answer: B
Rationale:
A. Bradycardia: Incorrect. Dehydration typically causes tachycardia due to decreased blood
volume, not bradycardia.
B. Dry mucous membranes: Correct. Dry mucous membranes are a hallmark sign of
dehydration due to reduced fluid availability in tissues.
