ATI RN FUNDAMENTALS CMS EXAM with Questions
and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Management of Care - 2. Safety and
Infection Control - 3. Health Promotion and Maintenance - 4.
Psychosocial Integrity - 5. Basic Care and Comfort - 6.
Pharmacology and Parenteral Therapies - 7. Reduction of
Risk Potential - 8. Physiological Adaptation
1. A nurse is planning care for a client who has a new prescription for a-tuberculin skin test (TST)
using the Mantoux method. Which of the following actions should the nurse plan to take?
A. Inject 0.1 mL of purified protein derivative intradermally with the bevel of the needle
pointing downward.
B. Inject 0.1 mL of purified protein derivative intradermally with the bevel of the needle
pointing upward.
C. Form a visible wheal that is 3 mm in diameter upon injection of the solution.
D. Massage the site vigorously following the injection to facilitate medication absorption.
CORRECT ANSWER : B
Rationale: The nurse should inject 0.1 mL of purified protein derivative intradermally, ensuring
the bevel of the needle is pointed upward to create the proper bleb or wheal. A wheal measuring
6 to 10 mm in diameter should form; a 3 mm wheal is too small and indicates improper injection
depth. Massaging the site is contraindicated because it can disperse the antigen and cause a
false-negative result.
2. A nurse is caring for an older adult client who is at risk for falls. Which of the following actions
should the nurse take to promote a safe environment?
A. Place the client's bed in the lowest position with the wheels locked.
B. Keep all four side rails raised at all times while the client is in bed.
C. Apply vest restraints whenever the client attempts to get out of bed unassisted.
D. Encourage the client to wear soft, loose-fitting slippers when ambulating in the room.
, CORRECT ANSWER : A
Rationale: Keeping the bed in the lowest position with wheels locked minimizes injury risk if a
client attempts to get out of bed. Raising all four side rails is considered a physical restraint
unless the client requests it or has specific safety indications. Restraints require a provider's
prescription and should be used only as a last resort. Clients should wear nonskid footwear
rather than loose slippers to prevent slipping.
3. A nurse is preparing to administer enteral feedings via a newly placed nasogastric (NG) tube.
Which of the following methods is the most reliable to verify tube placement prior to the initial
feeding?
A. Auscultating an air bolus injected into the tube over the epigastric area.
B. Testing the pH of aspirated fluid to ensure it is alkaline.
C. Obtaining an abdominal X-ray to confirm tube tip location.
D. Checking for the presence of carbon dioxide using a colorimetric capnometry detector.
CORRECT ANSWER : C
Rationale: An abdominal X-ray is the only definitive, highly reliable method to verify initial
nasogastric tube placement before the first feeding. Auscultation of an air bolus is unreliable
and no longer recommended by evidence-based standards. Gastric aspirate is typically acidic
(pH between 1 and 4), not alkaline. Capnometry is utilized to rule out airway placement during
blind insertions but does not confirm gastric placement.
4. A nurse is assessing a client who has been receiving intravenous (IV) normal saline via a
peripheral catheter for the past 3 days. The client reports pain and tenderness at the site, and the
nurse notes a red streak tracking along the vein pathway with palpable warmth. Which of the
following complications should the nurse document?
A. Infiltration
B. Fluid overload
C. Phlebitis
D. Hematoma
CORRECT ANSWER : C
Rationale: Phlebitis is an inflammation of the vein characterized by pain, tenderness, erythema
tracking along the vein, and warmth at the insertion site. Infiltration involves cool skin, swelling,
and damp dressings without a red streak. Fluid overload presents with crackles, dyspnea, and
, elevated blood pressure. A hematoma causes localized bruising, swelling, and leakage of blood
at the site.
5. A nurse is admitting a client who has active pulmonary tuberculosis. Which of the following
types of transmission-based precautions should the nurse implement?
A. Standard precautions alone
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
CORRECT ANSWER : D
Rationale: Tuberculosis is transmitted via droplet nuclei that remain suspended in the air for
prolonged periods, requiring airborne precautions. Airborne precautions include placing the
client in a negative-pressure airflow room and requiring staff to wear N95 or higher-level
respirators. Contact precautions are used for diseases spread via direct or indirect contact, such
as C. diff. Droplet precautions are used for pathogens spread via large-particle droplets, such as
influenza.
6. A nurse is caring for a client who is scheduled for an elective surgical procedure. The client
states, "I changed my mind; I do not want to have this surgery." Which of the following actions
should the nurse take first?
A. Notify the surgeon immediately that the client refuses the procedure.
B. Explore the client's reasons and concerns regarding the decision to refuse surgery.
C. Explain the severe medical consequences that will occur if the surgery is canceled.
D. Have the client sign an Against Medical Advice (AMA) form.
CORRECT ANSWER : B
Rationale: The nurse should first explore the client's reasons and concerns, as addressing
underlying fears or misunderstandings may help resolve their hesitation. While the surgeon must
be notified and an informed refusal form completed if the client maintains their decision,
coercion or judgment must be avoided. An AMA form is typically utilized when a hospitalized
client chooses to leave the facility prematurely, not strictly for refusing a single procedure.
7. A nurse is delegating vital sign measurements for a stable postoperative client to an assistive
personnel (AP). Which of the following instructions should the nurse provide to the AP?
, A. "Report any blood pressure reading that indicates the client is in pain."
B. "Report any systolic blood pressure reading greater than 140 or less than 90 millimeters
of mercury."
C. "Assess the client's level of consciousness while you measure their temperature."
D. "Determine if the client's postoperative pain is adequately controlled."
CORRECT ANSWER : B
Rationale: Providing specific numerical parameters gives the AP clear, objective thresholds for
when to immediately notify the nurse. Assessing pain levels, evaluating consciousness changes,
and interpreting clinical data require professional nursing judgment and cannot be delegated to
an AP.
8. A nurse is evaluating a client's understanding of a newly prescribed low-sodium diet to manage
heart failure. Which of the following client statements indicates a need for further teaching?
A. "I will use fresh herbs and lemon juice to season my meals instead of table salt."
B. "I will read the nutrition labels carefully to check the sodium content per serving."
C. "I can use canned vegetables and soups as long as I rinse them thoroughly under tap
water."
D. "I should avoid processed meats like deli turkey and cured ham."
CORRECT ANSWER : C
Rationale: Canned vegetables and soups are heavily processed with sodium preservatives that
cannot be completely removed by rinsing, making them high-sodium items that should be
avoided. Using fresh herbs, reading labels, and avoiding processed deli meats are correct health
promotion behaviors for a low-sodium diet.
9. A nurse is preparing to administer several oral medications to a client who has an enteral feeding
tube. Which of the following actions should the nurse take?
A. Crush enteric-coated tablets into a fine powder and mix them with water.
B. Flush the tube with 15 to 30 mL of warm water before and after administering each
medication.
C. Mix all prescribed medications together in a single syringe to expedite the administration
process.
and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Management of Care - 2. Safety and
Infection Control - 3. Health Promotion and Maintenance - 4.
Psychosocial Integrity - 5. Basic Care and Comfort - 6.
Pharmacology and Parenteral Therapies - 7. Reduction of
Risk Potential - 8. Physiological Adaptation
1. A nurse is planning care for a client who has a new prescription for a-tuberculin skin test (TST)
using the Mantoux method. Which of the following actions should the nurse plan to take?
A. Inject 0.1 mL of purified protein derivative intradermally with the bevel of the needle
pointing downward.
B. Inject 0.1 mL of purified protein derivative intradermally with the bevel of the needle
pointing upward.
C. Form a visible wheal that is 3 mm in diameter upon injection of the solution.
D. Massage the site vigorously following the injection to facilitate medication absorption.
CORRECT ANSWER : B
Rationale: The nurse should inject 0.1 mL of purified protein derivative intradermally, ensuring
the bevel of the needle is pointed upward to create the proper bleb or wheal. A wheal measuring
6 to 10 mm in diameter should form; a 3 mm wheal is too small and indicates improper injection
depth. Massaging the site is contraindicated because it can disperse the antigen and cause a
false-negative result.
2. A nurse is caring for an older adult client who is at risk for falls. Which of the following actions
should the nurse take to promote a safe environment?
A. Place the client's bed in the lowest position with the wheels locked.
B. Keep all four side rails raised at all times while the client is in bed.
C. Apply vest restraints whenever the client attempts to get out of bed unassisted.
D. Encourage the client to wear soft, loose-fitting slippers when ambulating in the room.
, CORRECT ANSWER : A
Rationale: Keeping the bed in the lowest position with wheels locked minimizes injury risk if a
client attempts to get out of bed. Raising all four side rails is considered a physical restraint
unless the client requests it or has specific safety indications. Restraints require a provider's
prescription and should be used only as a last resort. Clients should wear nonskid footwear
rather than loose slippers to prevent slipping.
3. A nurse is preparing to administer enteral feedings via a newly placed nasogastric (NG) tube.
Which of the following methods is the most reliable to verify tube placement prior to the initial
feeding?
A. Auscultating an air bolus injected into the tube over the epigastric area.
B. Testing the pH of aspirated fluid to ensure it is alkaline.
C. Obtaining an abdominal X-ray to confirm tube tip location.
D. Checking for the presence of carbon dioxide using a colorimetric capnometry detector.
CORRECT ANSWER : C
Rationale: An abdominal X-ray is the only definitive, highly reliable method to verify initial
nasogastric tube placement before the first feeding. Auscultation of an air bolus is unreliable
and no longer recommended by evidence-based standards. Gastric aspirate is typically acidic
(pH between 1 and 4), not alkaline. Capnometry is utilized to rule out airway placement during
blind insertions but does not confirm gastric placement.
4. A nurse is assessing a client who has been receiving intravenous (IV) normal saline via a
peripheral catheter for the past 3 days. The client reports pain and tenderness at the site, and the
nurse notes a red streak tracking along the vein pathway with palpable warmth. Which of the
following complications should the nurse document?
A. Infiltration
B. Fluid overload
C. Phlebitis
D. Hematoma
CORRECT ANSWER : C
Rationale: Phlebitis is an inflammation of the vein characterized by pain, tenderness, erythema
tracking along the vein, and warmth at the insertion site. Infiltration involves cool skin, swelling,
and damp dressings without a red streak. Fluid overload presents with crackles, dyspnea, and
, elevated blood pressure. A hematoma causes localized bruising, swelling, and leakage of blood
at the site.
5. A nurse is admitting a client who has active pulmonary tuberculosis. Which of the following
types of transmission-based precautions should the nurse implement?
A. Standard precautions alone
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
CORRECT ANSWER : D
Rationale: Tuberculosis is transmitted via droplet nuclei that remain suspended in the air for
prolonged periods, requiring airborne precautions. Airborne precautions include placing the
client in a negative-pressure airflow room and requiring staff to wear N95 or higher-level
respirators. Contact precautions are used for diseases spread via direct or indirect contact, such
as C. diff. Droplet precautions are used for pathogens spread via large-particle droplets, such as
influenza.
6. A nurse is caring for a client who is scheduled for an elective surgical procedure. The client
states, "I changed my mind; I do not want to have this surgery." Which of the following actions
should the nurse take first?
A. Notify the surgeon immediately that the client refuses the procedure.
B. Explore the client's reasons and concerns regarding the decision to refuse surgery.
C. Explain the severe medical consequences that will occur if the surgery is canceled.
D. Have the client sign an Against Medical Advice (AMA) form.
CORRECT ANSWER : B
Rationale: The nurse should first explore the client's reasons and concerns, as addressing
underlying fears or misunderstandings may help resolve their hesitation. While the surgeon must
be notified and an informed refusal form completed if the client maintains their decision,
coercion or judgment must be avoided. An AMA form is typically utilized when a hospitalized
client chooses to leave the facility prematurely, not strictly for refusing a single procedure.
7. A nurse is delegating vital sign measurements for a stable postoperative client to an assistive
personnel (AP). Which of the following instructions should the nurse provide to the AP?
, A. "Report any blood pressure reading that indicates the client is in pain."
B. "Report any systolic blood pressure reading greater than 140 or less than 90 millimeters
of mercury."
C. "Assess the client's level of consciousness while you measure their temperature."
D. "Determine if the client's postoperative pain is adequately controlled."
CORRECT ANSWER : B
Rationale: Providing specific numerical parameters gives the AP clear, objective thresholds for
when to immediately notify the nurse. Assessing pain levels, evaluating consciousness changes,
and interpreting clinical data require professional nursing judgment and cannot be delegated to
an AP.
8. A nurse is evaluating a client's understanding of a newly prescribed low-sodium diet to manage
heart failure. Which of the following client statements indicates a need for further teaching?
A. "I will use fresh herbs and lemon juice to season my meals instead of table salt."
B. "I will read the nutrition labels carefully to check the sodium content per serving."
C. "I can use canned vegetables and soups as long as I rinse them thoroughly under tap
water."
D. "I should avoid processed meats like deli turkey and cured ham."
CORRECT ANSWER : C
Rationale: Canned vegetables and soups are heavily processed with sodium preservatives that
cannot be completely removed by rinsing, making them high-sodium items that should be
avoided. Using fresh herbs, reading labels, and avoiding processed deli meats are correct health
promotion behaviors for a low-sodium diet.
9. A nurse is preparing to administer several oral medications to a client who has an enteral feeding
tube. Which of the following actions should the nurse take?
A. Crush enteric-coated tablets into a fine powder and mix them with water.
B. Flush the tube with 15 to 30 mL of warm water before and after administering each
medication.
C. Mix all prescribed medications together in a single syringe to expedite the administration
process.
