ATI COMPREHENSIVE FUNDAMENTALS RETAKE
(2019) VERIFIED QUESTIONS AND ANSWERS
WITH EXPLANATIONS || 100% GUARANTEED PASS
<RECENT VERSION>
1. A nurse is caring for a client who has a terminal illness. The client states, "I
just don't understand why this is happening to me." Which of the following
responses by the nurse is appropriate?
A. "You have lived a long and good life, so try not to be sad."
B. "It sounds like you are looking for meaning in your situation."
C. "Everyone dies eventually; it's a part of life."
D. "I think you should speak with the chaplain about your feelings."
Answer: B. "It sounds like you are looking for meaning in your situation."
Rationale: This response uses the therapeutic communication technique of
reflection, which acknowledges the client's feelings and encourages further
expression. It is open-ended and non-judgmental, allowing the client to explore
their emotions. Options A, C, and D are dismissive, philosophical, or deflect the
client's need to talk with the nurse.
2. A nurse is preparing to administer a cleansing enema to a client. In which
position should the nurse place the client?
A. Right lateral Sims' position
B. Left lateral Sims' position
C. Supine with the head of the bed elevated 45 degrees
D. Prone with a pillow under the abdomen
Answer: B. Left lateral Sims' position
Rationale: The left lateral Sims' position allows the enema solution to flow by
gravity along the natural curve of the sigmoid colon and rectum, improving
effectiveness and retention. The right lateral position would flow against the
natural curve.
3. A nurse is reviewing a client's medication list and notes a new prescription
for furosemide. The nurse should recognize that which of the following over-
the-counter medications can cause a potential interaction?
,A. Ibuprofen
B. Diphenhydramine
C. Calcium carbonate
D. Psyllium
Answer: A. Ibuprofen
Rationale: NSAIDs like ibuprofen can reduce the diuretic and antihypertensive
effects of furosemide. They can also increase the risk of nephrotoxicity when used
concurrently.
4. A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will change the pouch every day."
B. "I can use lotion on the skin around the stoma."
C. "I should expect the stoma to be a dark purple color."
D. "I will empty the pouch when it is one-third to one-half full."
Answer: D. "I will empty the pouch when it is one-third to one-half full."
*Rationale: Emptying the pouch before it becomes overfull prevents leakage and
pulling on the skin barrier. Pouches are typically changed every 3-7 days, not daily.
Lotions can interfere with the pouch seal. A stoma should be moist and red; a dark
purple color indicates ischemia.*
5. A nurse is assessing a client's peripheral pulses and notes a weak, thready
radial pulse. The nurse should document this finding as which grade?
A. 0
B. 1+
C. 2+
D. 3+
Answer: B. 1+
*Rationale: The scale for pulse amplitude is: 0 (absent), 1+ (weak/thready), 2+
(normal), 3+ (full/bounding), 4+ (strong/bounding).*
6. A nurse is caring for a client who requires a 24-hour urine collection. Which
of the following actions should the nurse take first?
A. Instruct the client to urinate and discard this first void.
B. Label the specimen container with the client's information.
,C. Place a sign above the client's bed about the procedure.
D. Provide the client with a specimen hat for the toilet.
Answer: A. Instruct the client to urinate and discard this first void.
*Rationale: The first action is to start the collection correctly. A 24-hour urine
collection always begins with an empty bladder. The client voids and discards that
first specimen, noting the time. All urine for the next 24 hours is then collected.*
7. A nurse is preparing to administer an intramuscular injection to a 6-month-
old infant. Which of the following sites is the safest and most appropriate?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Ventrogluteal
Answer: C. Vastus lateralis
*Rationale: The vastus lateralis is the preferred and safest site for infants and
children under 3 years old because it is large, well-developed, and lacks major
nerves and blood vessels. The deltoid is too small, the dorsogluteal is unsafe due to
proximity to the sciatic nerve, and the ventrogluteal is more suitable for older
children and adults.*
8. A nurse is reviewing the laboratory results of a client who is receiving IV
heparin. Which of the following values should the nurse monitor to determine
the therapeutic effect of the medication?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count
Answer: C. Activated Partial Thromboplastin Time (aPTT)
Rationale: aPTT is the primary test used to monitor the therapeutic effect of
unfractionated heparin. PT/INR is used to monitor warfarin therapy. Platelet count
is monitored for heparin-induced thrombocytopenia (HIT).
9. A nurse is teaching a client about a low-sodium diet. Which of the following
food choices by the client indicates an understanding of the teaching?
A. Canned soup
B. Deli turkey breast
, C. Fresh steamed broccoli
D. Pickled beets
Answer: C. Fresh steamed broccoli
Rationale: Fresh or frozen vegetables without added sauces are naturally low in
sodium. Canned soups, deli meats, and pickled foods are notoriously high in
sodium.
10. A nurse is caring for a client who has a prescription for wrist restraints.
Which of the following actions should the nurse take?
A. Secure the restraint with a square knot.
B. Remove the restraint every 4 hours.
C. Ensure two fingers can fit between the restraint and the client's skin.
D. Tie the restraint to the movable part of the bed frame.
Answer: C. Ensure two fingers can fit between the restraint and the
client's skin.
*Rationale: This ensures the restraint is not too tight, which could impair
circulation. Restraints must be removed and the skin assessed at least every 2
hours. They should be secured with a quick-release knot and tied to a stationary,
non-movable part of the bed frame.*
11. A nurse is planning care for a client who has difficulty swallowing. Which
of the following interventions should the nurse include?
A. Tilt the client's head backward when swallowing.
B. Encourage the client to take large bites.
C. Place food on the unaffected side of the mouth.
D. Instruct the client to talk while eating.
Answer: C. Place food on the unaffected side of the mouth.
Rationale: Placing food on the unaffected side facilitates chewing and swallowing
and reduces the risk of aspiration. The head should be tilted slightly forward, not
backward. Small bites should be encouraged, and the client should not talk while
eating to focus on the swallowing process.
12. A nurse is assessing a client's breath sounds and hears a low-pitched,
snoring sound over the trachea and mainstem bronchi. The nurse should
document this as which of the following?
A. Wheezes
(2019) VERIFIED QUESTIONS AND ANSWERS
WITH EXPLANATIONS || 100% GUARANTEED PASS
<RECENT VERSION>
1. A nurse is caring for a client who has a terminal illness. The client states, "I
just don't understand why this is happening to me." Which of the following
responses by the nurse is appropriate?
A. "You have lived a long and good life, so try not to be sad."
B. "It sounds like you are looking for meaning in your situation."
C. "Everyone dies eventually; it's a part of life."
D. "I think you should speak with the chaplain about your feelings."
Answer: B. "It sounds like you are looking for meaning in your situation."
Rationale: This response uses the therapeutic communication technique of
reflection, which acknowledges the client's feelings and encourages further
expression. It is open-ended and non-judgmental, allowing the client to explore
their emotions. Options A, C, and D are dismissive, philosophical, or deflect the
client's need to talk with the nurse.
2. A nurse is preparing to administer a cleansing enema to a client. In which
position should the nurse place the client?
A. Right lateral Sims' position
B. Left lateral Sims' position
C. Supine with the head of the bed elevated 45 degrees
D. Prone with a pillow under the abdomen
Answer: B. Left lateral Sims' position
Rationale: The left lateral Sims' position allows the enema solution to flow by
gravity along the natural curve of the sigmoid colon and rectum, improving
effectiveness and retention. The right lateral position would flow against the
natural curve.
3. A nurse is reviewing a client's medication list and notes a new prescription
for furosemide. The nurse should recognize that which of the following over-
the-counter medications can cause a potential interaction?
,A. Ibuprofen
B. Diphenhydramine
C. Calcium carbonate
D. Psyllium
Answer: A. Ibuprofen
Rationale: NSAIDs like ibuprofen can reduce the diuretic and antihypertensive
effects of furosemide. They can also increase the risk of nephrotoxicity when used
concurrently.
4. A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will change the pouch every day."
B. "I can use lotion on the skin around the stoma."
C. "I should expect the stoma to be a dark purple color."
D. "I will empty the pouch when it is one-third to one-half full."
Answer: D. "I will empty the pouch when it is one-third to one-half full."
*Rationale: Emptying the pouch before it becomes overfull prevents leakage and
pulling on the skin barrier. Pouches are typically changed every 3-7 days, not daily.
Lotions can interfere with the pouch seal. A stoma should be moist and red; a dark
purple color indicates ischemia.*
5. A nurse is assessing a client's peripheral pulses and notes a weak, thready
radial pulse. The nurse should document this finding as which grade?
A. 0
B. 1+
C. 2+
D. 3+
Answer: B. 1+
*Rationale: The scale for pulse amplitude is: 0 (absent), 1+ (weak/thready), 2+
(normal), 3+ (full/bounding), 4+ (strong/bounding).*
6. A nurse is caring for a client who requires a 24-hour urine collection. Which
of the following actions should the nurse take first?
A. Instruct the client to urinate and discard this first void.
B. Label the specimen container with the client's information.
,C. Place a sign above the client's bed about the procedure.
D. Provide the client with a specimen hat for the toilet.
Answer: A. Instruct the client to urinate and discard this first void.
*Rationale: The first action is to start the collection correctly. A 24-hour urine
collection always begins with an empty bladder. The client voids and discards that
first specimen, noting the time. All urine for the next 24 hours is then collected.*
7. A nurse is preparing to administer an intramuscular injection to a 6-month-
old infant. Which of the following sites is the safest and most appropriate?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Ventrogluteal
Answer: C. Vastus lateralis
*Rationale: The vastus lateralis is the preferred and safest site for infants and
children under 3 years old because it is large, well-developed, and lacks major
nerves and blood vessels. The deltoid is too small, the dorsogluteal is unsafe due to
proximity to the sciatic nerve, and the ventrogluteal is more suitable for older
children and adults.*
8. A nurse is reviewing the laboratory results of a client who is receiving IV
heparin. Which of the following values should the nurse monitor to determine
the therapeutic effect of the medication?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count
Answer: C. Activated Partial Thromboplastin Time (aPTT)
Rationale: aPTT is the primary test used to monitor the therapeutic effect of
unfractionated heparin. PT/INR is used to monitor warfarin therapy. Platelet count
is monitored for heparin-induced thrombocytopenia (HIT).
9. A nurse is teaching a client about a low-sodium diet. Which of the following
food choices by the client indicates an understanding of the teaching?
A. Canned soup
B. Deli turkey breast
, C. Fresh steamed broccoli
D. Pickled beets
Answer: C. Fresh steamed broccoli
Rationale: Fresh or frozen vegetables without added sauces are naturally low in
sodium. Canned soups, deli meats, and pickled foods are notoriously high in
sodium.
10. A nurse is caring for a client who has a prescription for wrist restraints.
Which of the following actions should the nurse take?
A. Secure the restraint with a square knot.
B. Remove the restraint every 4 hours.
C. Ensure two fingers can fit between the restraint and the client's skin.
D. Tie the restraint to the movable part of the bed frame.
Answer: C. Ensure two fingers can fit between the restraint and the
client's skin.
*Rationale: This ensures the restraint is not too tight, which could impair
circulation. Restraints must be removed and the skin assessed at least every 2
hours. They should be secured with a quick-release knot and tied to a stationary,
non-movable part of the bed frame.*
11. A nurse is planning care for a client who has difficulty swallowing. Which
of the following interventions should the nurse include?
A. Tilt the client's head backward when swallowing.
B. Encourage the client to take large bites.
C. Place food on the unaffected side of the mouth.
D. Instruct the client to talk while eating.
Answer: C. Place food on the unaffected side of the mouth.
Rationale: Placing food on the unaffected side facilitates chewing and swallowing
and reduces the risk of aspiration. The head should be tilted slightly forward, not
backward. Small bites should be encouraged, and the client should not talk while
eating to focus on the swallowing process.
12. A nurse is assessing a client's breath sounds and hears a low-pitched,
snoring sound over the trachea and mainstem bronchi. The nurse should
document this as which of the following?
A. Wheezes
