ATI PN FUNDAMENTALS 2025 PROCTORED EXAM 70
QUESTIONS WITH DETAILED VERIFIED SOLUTIONS
AND RATIONALE /A+ GRADE ASSURED
1. A nurse is preparing to administer a cleansing enema to a client. In which position should the
nurse place the client?
Answer: Left Sim's position with the right leg flexed.
Rationale: This position allows the enema solution to flow by gravity along the natural curve of
the sigmoid colon, enhancing effectiveness and comfort.
2. A nurse is caring for a client who requires a 24-hour urine specimen collection. What is the
correct first action by the nurse?
Answer: Discard the first voided urine.
Rationale: The collection starts with an empty bladder. The first void is discarded, and the time is
noted as the start time. All urine for the next 24 hours is then collected.
3. A nurse is implementing droplet precautions for a client with influenza. Which action must the
nurse take?
Answer: Wear a surgical mask when working within 3 feet of the client.
Rationale: Droplet precautions require a mask for close contact (typically within 3 feet or 1
meter) to protect against large-particle droplets expelled during coughing, sneezing, or talking.
4. A nurse is assessing a client's pedal pulses. The pulse is difficult to palpate and rates a "1" on a
0-4+ scale. How should the nurse document this finding?
Answer: Diminished or weak pulse.
Rationale: A pulse amplitude of 1+ is described as diminished, weak, or barely palpable,
indicating reduced blood flow to the area.
5. A client has a new prescription for a low-sodium diet. Which food choice by the client
indicates an understanding of the teaching?
Answer: Grilled chicken breast with steamed vegetables.
Rationale: Fresh, unprocessed meats and vegetables are naturally lower in sodium compared to
canned, processed, or pickled foods.
, 6. A nurse is delegating the task of vital sign measurement to an assistive personnel (AP) for a
stable client. What instruction should the nurse provide?
Answer: "Please measure the vital signs and report any abnormal findings to me immediately."
Rationale: The nurse is responsible for assessment and interpretation of data. The AP can collect
data but must report abnormalities for the nurse to analyze.
7. A nurse needs to use the nursing process to develop a care plan. What is the first step of this
process?
Answer: Assessment.
Rationale: The nursing process follows the sequence of Assessment, Diagnosis, Planning,
Implementation, and Evaluation (ADPIE). Assessment, the collection of data, must always come
first.
8. A client is experiencing dysphagia following a stroke. Which nursing intervention is the
highest priority during meals?
Answer: Maintaining upright positioning at 90 degrees during and for 30 minutes after the meal.
Rationale: This position uses gravity to facilitate swallowing and reduces the risk of aspiration,
which is a life-threatening complication.
9. A nurse is preparing to administer an intramuscular (IM) injection using the Z-track method.
What is the primary purpose of this technique?
Answer: To prevent medication from leaking into the subcutaneous tissue.
Rationale: The Z-track technique seals the medication deep within the muscle tissue, minimizing
skin irritation and staining.
10. A client tells the nurse, "I'm in so much pain, I can't take it anymore." What is the nurse's
most therapeutic response?
Answer: "Tell me more about your pain."
Rationale: This open-ended statement encourages the client to elaborate, allowing the nurse to
perform a more comprehensive pain assessment.
11. A nurse is providing postmortem care. Which action is the priority?
QUESTIONS WITH DETAILED VERIFIED SOLUTIONS
AND RATIONALE /A+ GRADE ASSURED
1. A nurse is preparing to administer a cleansing enema to a client. In which position should the
nurse place the client?
Answer: Left Sim's position with the right leg flexed.
Rationale: This position allows the enema solution to flow by gravity along the natural curve of
the sigmoid colon, enhancing effectiveness and comfort.
2. A nurse is caring for a client who requires a 24-hour urine specimen collection. What is the
correct first action by the nurse?
Answer: Discard the first voided urine.
Rationale: The collection starts with an empty bladder. The first void is discarded, and the time is
noted as the start time. All urine for the next 24 hours is then collected.
3. A nurse is implementing droplet precautions for a client with influenza. Which action must the
nurse take?
Answer: Wear a surgical mask when working within 3 feet of the client.
Rationale: Droplet precautions require a mask for close contact (typically within 3 feet or 1
meter) to protect against large-particle droplets expelled during coughing, sneezing, or talking.
4. A nurse is assessing a client's pedal pulses. The pulse is difficult to palpate and rates a "1" on a
0-4+ scale. How should the nurse document this finding?
Answer: Diminished or weak pulse.
Rationale: A pulse amplitude of 1+ is described as diminished, weak, or barely palpable,
indicating reduced blood flow to the area.
5. A client has a new prescription for a low-sodium diet. Which food choice by the client
indicates an understanding of the teaching?
Answer: Grilled chicken breast with steamed vegetables.
Rationale: Fresh, unprocessed meats and vegetables are naturally lower in sodium compared to
canned, processed, or pickled foods.
, 6. A nurse is delegating the task of vital sign measurement to an assistive personnel (AP) for a
stable client. What instruction should the nurse provide?
Answer: "Please measure the vital signs and report any abnormal findings to me immediately."
Rationale: The nurse is responsible for assessment and interpretation of data. The AP can collect
data but must report abnormalities for the nurse to analyze.
7. A nurse needs to use the nursing process to develop a care plan. What is the first step of this
process?
Answer: Assessment.
Rationale: The nursing process follows the sequence of Assessment, Diagnosis, Planning,
Implementation, and Evaluation (ADPIE). Assessment, the collection of data, must always come
first.
8. A client is experiencing dysphagia following a stroke. Which nursing intervention is the
highest priority during meals?
Answer: Maintaining upright positioning at 90 degrees during and for 30 minutes after the meal.
Rationale: This position uses gravity to facilitate swallowing and reduces the risk of aspiration,
which is a life-threatening complication.
9. A nurse is preparing to administer an intramuscular (IM) injection using the Z-track method.
What is the primary purpose of this technique?
Answer: To prevent medication from leaking into the subcutaneous tissue.
Rationale: The Z-track technique seals the medication deep within the muscle tissue, minimizing
skin irritation and staining.
10. A client tells the nurse, "I'm in so much pain, I can't take it anymore." What is the nurse's
most therapeutic response?
Answer: "Tell me more about your pain."
Rationale: This open-ended statement encourages the client to elaborate, allowing the nurse to
perform a more comprehensive pain assessment.
11. A nurse is providing postmortem care. Which action is the priority?
