Fundamentals ATI Questions - Exam 1 ACCURATE TESTED VERSIONS OF THE EXAM FROM 2025 TO 2026 | ACCURATE AND VERIFIED ANSWERS | NEXT GEN FORMAT | GUARANTEED PASS

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? A. Hold the container of solution 15 cm (6 in) above the anus B. Hold the container of solution 30 cm (12 in) above the anus C. Insert the rectal tube 2.5 cm (1 in) into the rectum D. Clamp the tubing before inserting into the anus Correct Answer: B. Hold the container of solution 30 cm (12 in) above the anus Rationale: Holding the container 30 cm allows proper flow of solution without causing excessive pressure and discomfort. A nurse is admitting a client who reports anorexia and malnutrition. Which laboratory finding should the nurse expect to be altered? A. Hemoglobin B. Albumin C. Potassium D. Sodium Correct Answer: B. Albumin Rationale: Albumin is a plasma protein that reflects long-term nutritional status. Low albumin is common in malnutrition. A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? A. Open the first flap toward the body B. Reach around the pack and open the top flap away from the body C. Keep hands directly over the sterile field D. Place items on the outer 1 inch border Correct Answer: B. Reach around the pack and open the top flap away from the body Rationale: Opening the top flap away prevents contamination by keeping the nurse’s body away from the sterile field. A nurse is assessing a client with prostatic hypertrophy. Which findings indicate urinary retention? (Select all that apply) A. Report of feeling pressure B. Tenderness over the symphysis pubis C. Distended bladder D. Voiding 30 mL frequently E. Clear, large urine output Correct Answers: A, B, C, D Rationale: These are classic signs of urinary retention from prostate enlargement; frequent small voids and bladder distention occur. A nurse is preparing to administer ophthalmic solution. Which of the following actions should the nurse take? A. Hold the dropper 5 cm above the eye B. Rest the dropper tip on the lower eyelid C. Hold the ophthalmic solution 2 cm above the lower conjunctival sac D. Place drops directly on the cornea Correct Answer: C. Hold the ophthalmic solution 2 cm above the lower conjunctival sac Rationale: Holding 2 cm above the conjunctival sac ensures accuracy while preventing injury and contamination. A nurse has just finished a wound irrigation for a client on contact precautions. Which PPE should the nurse remove first? A. Gloves B. Gown C. Goggles D. Mask Correct Answer: A. Gloves Rationale: Gloves are the most contaminated PPE and should be removed first to reduce risk of cross-contamination. A nurse in a long-term care facility notices a client choking. Which situation requires the Heimlich maneuver? A. The client is coughing forcefully B. The client is gasping for air and speaking in short phrases C. The client is not making any sounds D. The client is breathing rapidly Correct Answer: C. The client is not making any sounds Rationale: Inability to cough, speak, or make sounds indicates complete airway obstruction requiring immediate Heimlich maneuver. A nurse is planning care for an older adult at risk for pressure ulcers. Which intervention best maintains skin integrity? A. Encourage sitting in bed with pillows B. Use a transfer device to lift the client up in bed C. Massage reddened areas to stimulate blood flow D. Apply baby powder to absorb moisture Correct Answer: B. Use a transfer device to lift the client up in bed Rationale: Using a transfer device prevents friction and shear forces, which help reduce the risk of pressure ulcers. A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto gauze. Which is the correct sequence? A. Remove cap → pour solution → hold bottle with label outward → recap bottle B. Remove cap → place cap face up → hold bottle with label facing palm → pour 1–2 mL → pour solution on gauze C. Shake bottle → pour directly → replace cap D. Remove cap → place cap down → pour solution → discard bottle Correct Answer: B. Rationale: Correct sequence prevents contamination and ensures sterile technique. A nurse is filling out an incident report after finding a client on the floor. Which information should the nurse include? A. "The client slipped because the floor was wet." B. "The client was lying on the floor next to his bed." C. "The client is likely confused and unsteady." D. "The client had tried to get to the bathroom alone." Correct Answer: B. The client was lying on the floor next to his bed Rationale: Incident reports should state only objective, factual observations without assumptions or blame. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests respite care services. A family member asks how respite care can help. Which response should the nurse provide? A. “Respite care provides financial support for medical supplies.” B. “Respite care allows the primary caregiver time away from daily responsibilities.” C. “Respite care replaces the caregiver permanently with home health staff.” D. “Respite care provides physical therapy at home.” Correct Answer: B. Rationale: Respite care gives caregivers temporary relief so they can rest, preventing burnout. A nurse is helping an older adult client ambulate with her walker. Which action ensures safety? A. Instruct the client to slide the walker forward B. Check that the client lifts the walker and places it in front C. Have the client push the walker while walking quickly D. Ensure the client leans heavily on the walker while moving Correct Answer: B. Rationale: The client should lift the walker and place it down to prevent tripping and ensure stability. A nurse is caring for a client with emphysema who is immobile in a reclining chair. Which physiological response to immobility should the nurse expect? A. Increased appetite B. Increased calcium excretion C. Decreased sodium retention D. Decreased protein breakdown Correct Answer: B. Rationale: Immobility leads to bone demineralization and increased calcium excretion, increasing risk for kidney stones and osteoporosis. A nurse is orienting new assistive personnel (AP). For which action should the nurse intervene? A. Washes hands with soap and water for 15 seconds B. Uses alcohol-based rub before client contact C. Washes and rinses hands for 10 seconds D. Turns off faucet with a paper towel Correct Answer: C. Rationale: Proper handwashing requires at least 15–20 seconds; 10 seconds is inadequate. A nurse provides preoperative teaching about antiembolism stockings. Which response by the client shows understanding? A. “They keep my legs warm after surgery.” B. “They improve circulation to prevent pooling of blood in my legs.” C. “They reduce my risk of infection.” D. “They help me walk without assistance.” Correct Answer: B. Rationale: Antiembolism stockings improve venous return and reduce risk of DVT. A nurse is caring for an older adult who is increasingly restless and confused. Which action ensures safety? A. Restrain the client to prevent falls B. Move client to a room closer to the nurses’ station C. Administer sedation as needed D. Turn off lights and close the door Correct Answer: B. Rationale: Placing the client near the nurses’ station allows close monitoring and quick intervention. A nurse is explaining rehabilitation care to the family of a client with a fractured hip. Which statement is appropriate? A. “Rehabilitation services start when the client is discharged from the hospital.” B. “Rehabilitation services begin with admission to the hospital.” C. “Rehabilitation care is only provided in nursing homes.” D. “Rehabilitation care focuses only on physical therapy.” Correct Answer: B. Rationale: Rehabilitation begins at admission and continues throughout hospitalization and recovery. A nurse is caring for an immobile client. Which action is the priority? A. Change position every 2 hrs B. Monitor urine output every 4 hrs C. Auscultate breath sounds at least every 2 hrs D. Encourage fluid intake Correct Answer: C. Rationale: Airway and breathing are highest priority; immobility increases risk of pneumonia and atelectasis. A nurse is assessing bowel sounds. When should the nurse auscultate the abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After the client eats D. Before asking the client to void Correct Answer: B. Rationale: Auscultation must occur before palpation or percussion because these can alter bowel sounds. A charge nurse is planning room assignments. Which client should be placed closest to the nurses’ station? A. A client with a urinary tract infection B. A client with diabetes mellitus C. A client with a head injury and periods of confusion D. A client recovering from elective surgery Correct Answer: C. Rationale: Clients with confusion and neurological risk require closer observation to prevent injury. A nurse is preparing an in-service on restraints. Which criterion should the nurse include for applying restraints? A. Family requests the client be restrained B. The nurse has already considered alternatives to restraints C. The client refuses medication D. Restraints may be used for staff convenience Correct Answer: B. Rationale: Restraints are used only when alternatives have been attempted and the client’s safety is at risk. A nurse is caring for a client with an NG tube receiving enteral feedings. Which action should the nurse take before feeding? A. Check for residual volume only B. Test the pH of gastric aspirate C. Flush tube with 50 mL water D. Ask client if stomach feels empty Correct Answer: B. Rationale: Testing pH confirms placement and reduces aspiration risk. A nurse removes an indwelling urinary catheter from an older adult. Which outcome should the nurse expect? A. Continuous urinary incontinence B. Temporary urinary retention C. Increased urinary frequency D. Complete loss of bladder sensation Correct Answer: B. Rationale: Temporary urinary retention is common until bladder tone and function return.