2025 ATI PN FUNDAMENTALS PROCTORED EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES GRADED A+ ASSURED SUCCESS
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a
long-term care facility. Using this scale, which of the following parameters should
the nurse evaluate?
1. incontinence
2. mental state
3. nutrition
4. general physical condition
- ANSWER- Nutrition ; nutrition, sensory perception,
moisture, activity, mobility, and friction and shear are the parameters of the Braden
scale for determining a client's risk for developing pressure ulcers. Incontinence,
mental state, and general physical condition are parameters on the Norton scale.
A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk for which of the following health alterations?
1. increased intestinal motility
2. respiratory alkalosis
3. decreased cardiac output
4. hypocalcemia
- ANSWER- Decreased cardiac output ; with immobility, the
heart rate increases to compensate for increased venous pooling. Hypoventilation
will lead to CO2 retention and respiratory acidosis.
A nurse is reinforcing teaching with an older adult client who has constipation.
Which of the following statements should the nurse include in the teaching?
1. Drink minimum 1L of fluid daily
2. increase your intake of refined-fiber foods
3. sit on the toilet 30 minutes after eating a meal
4. take a laxative every day to maintain regularity
- ANSWER- Sit on the toilet 30
min after eating a meal ; increased peristalsis occurs after food enters the
stomach. This is a recommended method of bowel retraining to treat constipation.
Consume at least 1.5L of fluid. Increase consumption of coarse fiber and whole
grains.
A nurse is caring for a client who has peripheral edema. The nurse should
identify that which of the following nutrients regulates extracellular fluid
volume?
1. sodium
2. calcium
3. potassium
4. magnesium
, - ANSWER- Sodium ; regulates extracellular fluid balance as well
as nerve impulse transmission, acid-base balance.
A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse
should identify that which of the following nutrients will be affected by the lack of
salivary amylase?
1. fat
2. protein
3. starch
4. fiber
- ANSWER- Starch ; majority of starch breakdown occurs in the small
intestine with pancreatic amylase. Lipase breaks down fats. Pepsin breaks down
proteins.
A nurse is caring for a client who has a deficiency in vitamin D. Which of the
following foods should the nurse recommend the client include in his diet?
1. whole milk
2. chicken
3. oranges
4. dried peas
- ANSWER- Whole milk ; it is often fortified with vitamin D and
contains vitamins A and K. Chicken contains many of the B complex vitamins.
Oranges are a good source of vitamin C.
A nurse is planning to administer diphenhydramine hydrochloride to an older
adults client. Which of the following actions should the nurse take prior to
administration?
1. review the client's medical record for a history of glaucoma
2. plan to administer medication 30 minutes before a meal
3. explain that he will need to restrict his fluid intake
4. remind the client that his appetite might increase when starting the medications
-ANSWER- Review the client's medical record for a history of glaucoma ;
diphenhydramine is contraindicated for clients who have narrow-angle glaucoma.
The client should increase fluid intake. Anorexia, nausea, and vomiting are GI
adverse effects of this medication.
A nurse is caring for an older adult client who has a hip fracture and is rating his
pain 8/10. Which of the following medications should the nurse administer?
1. capsaicin topical gel
2. oxycodone/acetaminophen
3. celecoxib
4. aspirin
- ANSWER- Oxycodone/acetaminophen ; this is a combination of an
opioid and nonopioid analgesic for severe pain. Monitor for adverse effects such as
respiratory depression.
, 1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and
intense sadness are symptoms of which stage?
a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining,
depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness
indicate depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and
others. In bargaining, the client asks God for more time, and in return promises to do something good.
2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore,
encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or
repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and
supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because
the additional calcium doesn’t increase bone stimulation or osteoblast activity.
3. Which statement regarding heart sounds is correct?
a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than
the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.
When planning this client’s care, the nurse should include which intervention? a. Increasing
fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and
coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor
coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated
unless other measures fail to clear the airway.
5. A nurse is using the computer when a client calls for pain medication. Which action by
the nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer.
A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal
without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe
computer practice.
6. What is the most appropriate nursing diagnosis for the client with
acute pancreatitis? a. Deficient fluid volume
b. Excess fluid volume
c. Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES GRADED A+ ASSURED SUCCESS
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a
long-term care facility. Using this scale, which of the following parameters should
the nurse evaluate?
1. incontinence
2. mental state
3. nutrition
4. general physical condition
- ANSWER- Nutrition ; nutrition, sensory perception,
moisture, activity, mobility, and friction and shear are the parameters of the Braden
scale for determining a client's risk for developing pressure ulcers. Incontinence,
mental state, and general physical condition are parameters on the Norton scale.
A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk for which of the following health alterations?
1. increased intestinal motility
2. respiratory alkalosis
3. decreased cardiac output
4. hypocalcemia
- ANSWER- Decreased cardiac output ; with immobility, the
heart rate increases to compensate for increased venous pooling. Hypoventilation
will lead to CO2 retention and respiratory acidosis.
A nurse is reinforcing teaching with an older adult client who has constipation.
Which of the following statements should the nurse include in the teaching?
1. Drink minimum 1L of fluid daily
2. increase your intake of refined-fiber foods
3. sit on the toilet 30 minutes after eating a meal
4. take a laxative every day to maintain regularity
- ANSWER- Sit on the toilet 30
min after eating a meal ; increased peristalsis occurs after food enters the
stomach. This is a recommended method of bowel retraining to treat constipation.
Consume at least 1.5L of fluid. Increase consumption of coarse fiber and whole
grains.
A nurse is caring for a client who has peripheral edema. The nurse should
identify that which of the following nutrients regulates extracellular fluid
volume?
1. sodium
2. calcium
3. potassium
4. magnesium
, - ANSWER- Sodium ; regulates extracellular fluid balance as well
as nerve impulse transmission, acid-base balance.
A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse
should identify that which of the following nutrients will be affected by the lack of
salivary amylase?
1. fat
2. protein
3. starch
4. fiber
- ANSWER- Starch ; majority of starch breakdown occurs in the small
intestine with pancreatic amylase. Lipase breaks down fats. Pepsin breaks down
proteins.
A nurse is caring for a client who has a deficiency in vitamin D. Which of the
following foods should the nurse recommend the client include in his diet?
1. whole milk
2. chicken
3. oranges
4. dried peas
- ANSWER- Whole milk ; it is often fortified with vitamin D and
contains vitamins A and K. Chicken contains many of the B complex vitamins.
Oranges are a good source of vitamin C.
A nurse is planning to administer diphenhydramine hydrochloride to an older
adults client. Which of the following actions should the nurse take prior to
administration?
1. review the client's medical record for a history of glaucoma
2. plan to administer medication 30 minutes before a meal
3. explain that he will need to restrict his fluid intake
4. remind the client that his appetite might increase when starting the medications
-ANSWER- Review the client's medical record for a history of glaucoma ;
diphenhydramine is contraindicated for clients who have narrow-angle glaucoma.
The client should increase fluid intake. Anorexia, nausea, and vomiting are GI
adverse effects of this medication.
A nurse is caring for an older adult client who has a hip fracture and is rating his
pain 8/10. Which of the following medications should the nurse administer?
1. capsaicin topical gel
2. oxycodone/acetaminophen
3. celecoxib
4. aspirin
- ANSWER- Oxycodone/acetaminophen ; this is a combination of an
opioid and nonopioid analgesic for severe pain. Monitor for adverse effects such as
respiratory depression.
, 1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and
intense sadness are symptoms of which stage?
a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining,
depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness
indicate depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and
others. In bargaining, the client asks God for more time, and in return promises to do something good.
2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore,
encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or
repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and
supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because
the additional calcium doesn’t increase bone stimulation or osteoblast activity.
3. Which statement regarding heart sounds is correct?
a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than
the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.
When planning this client’s care, the nurse should include which intervention? a. Increasing
fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and
coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor
coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated
unless other measures fail to clear the airway.
5. A nurse is using the computer when a client calls for pain medication. Which action by
the nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer.
A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal
without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe
computer practice.
6. What is the most appropriate nursing diagnosis for the client with
acute pancreatitis? a. Deficient fluid volume
b. Excess fluid volume
c. Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
