ATI Fundamentals Test Exam 2 QUESTIONS
AND ANSWERS WITH RATIONALES/ GRADED
A+/100%CORRECT (2026/2027 Edition)
Course: NURS 101
Section 1: Safety & Infection Control (Questions 1-30)
1. A nurse is preparing to insert an NG tube for a client with a bowel obstruction. Which action is most
important to prevent aspiration?
A. Lubricate the tube with water-soluble jelly.
B. Place the client in High-Fowler's position.
C. Instruct the client to tilt their head backward.
D. Have the client take sips of water.
Correct Answer: B. High-Fowler's position (sitting upright at 90 degrees) uses gravity to prevent fluid
from flowing back into the pharynx, reducing the risk of aspiration .
• Rationale for A: Lubricant reduces friction but does not prevent aspiration.
• Rationale for C: Tilting the head back opens the airway but actually increases aspiration risk.
• Rationale for D: Water assists swallowing but is not the primary safety mechanism compared to
positioning.
2. A client is on "Airborne Precautions." Which PPE must the nurse wear when entering the room?
A. Surgical mask
B. N95 respirator mask
C. Gown and gloves only
D. Face shield
Correct Answer: B. Airborne precautions (e.g., TB, Measles, Varicella) require an N95 respirator (or
higher) to filter small airborne particles .
• Rationale for A: Surgical masks protect against Droplet (large particles) only.
• Rationale for C: Required for Contact precautions.
• Rationale for D: Required for procedures with splash risk.
3. A nurse discovers a small fire in a client's trash can. What is the priority action?
A. Pull the fire alarm.
B. Attempt to extinguish the fire.
,C. Evacuate the client.
D. Close the client's door.
Correct Answer: C. RACE: Rescue, Alarm, Confine, Extinguish. Removing the client from immediate
danger is the priority .
• Rationale for A: This happens after rescue.
• Rationale for B: Only attempt if the fire is small and you have been trained (after rescue).
• Rationale for D: Done to contain fire (Confine), but rescue comes first.
4. A client is ordered wrist restraints. Which action indicates proper use?
A. Tie the restraints to the side rail.
B. Apply the restraints tightly to prevent slipping.
C. Tie the restraints using a quick-release knot.
D. Remove the restraints every 4 hours.
Correct Answer: C. A quick-release knot allows for immediate removal in an emergency .
• Rationale for A: Restraints tie to the bed frame (movable part), not the side rail (which lowers).
• Rationale for B: Must allow 1-2 fingers of slack to prevent circulatory damage.
• Rationale for D: Restraints must be removed every 2 hours for ROM and skin check.
5. The nurse is preparing to irrigate a wound. Which step maintains sterile technique?
A. Opening the sterile package away from the body.
B. Holding the bottle of sterile solution upside down to pour.
C. Reaching over the sterile field to grab a gauze.
D. Allowing the solution to flow over the 1-inch border.
Correct Answer: A. The first flap of a sterile package is opened away from the body to prevent the arm
from contaminating the field. The 1-inch border of a sterile field is considered contaminated .
• Rationale for B: Avoid splashing; hold label up so liquid doesn't ruin label, but lid should be
directed away.
• Rationale for C: Never reach over a sterile field; go around.
• Rationale for D: The 1-inch border is contaminated.
6. A nurse is caring for a client with TB. Which type of room pressure is required?
A. Positive pressure
B. Negative pressure
C. Neutral pressure
D. Reverse isolation
Correct Answer: B. Negative pressure prevents air from flowing out into the hallway when the door is
opened, containing the pathogen.
• Rationale for A: Positive pressure is for protective environment (immunocompromised).
, • Rationale for C/D: Not standard for airborne isolation.
7. Which client requires Droplet precautions?
A. Client with C. diff.
B. Client with Meningitis.
C. Client with Scabies.
D. Client with Open wound.
Correct Answer: B. Meningitis (bacterial) is spread via large respiratory droplets .
• Rationale for A & C: Contact precautions (skin/environment).
• Rationale for D: Standard precautions only.
8. The nurse is applying antiembolic stockings (TED hose). Which technique is correct?
A. Roll the stocking down at the top if it is too long.
B. Turn the stocking inside out to the heel before applying.
C. Have the client sit on the side of the bed.
D. Remove the stockings every 72 hours.
Correct Answer: B. Rolling the stocking inside out to the heel allows for easier application and prevents
constrictive wrinkles .
• Rationale for A: Rolling causes a tourniquet effect (DVT risk).
• Rationale for C: Client should be supine to apply (legs elevated).
• Rationale for D: Remove once per shift (q8-12h) for skin assessment.
9. A client falls in the bathroom. What is the nurse's first action?
A. Fill out an incident report.
B. Notify the physician.
C. Assess the client for injury.
D. Move the client back to bed.
Correct Answer: C. Assessment is always first (ABCs). You must determine injuries before moving the
client .
• Rationale for A/D: Documentation and moving occur after assessment.
• Rationale for B: Notify provider after assessment and vitals.
10. Which finding indicates a stage 2 pressure injury?
A. Intact skin with non-blanchable redness.
B. Partial-thickness skin loss with visible dermis.
C. Full-thickness tissue loss with visible bone.
D. Eschar covering the wound bed.
Correct Answer: B. Stage 2 is a break in the skin (blister or shallow ulcer) involving the
epidermis/dermis .
, • Rationale for A: Stage 1.
• Rationale for C: Stage 3 or 4 (SubQ fat exposed is stage 3).
• Rationale for D: Unstageable.
11. When using a cane, the client should hold the cane...
A. On the weak side.
B. On the strong side.
C. 24 inches in front of them.
D. In the dominant hand.
Correct Answer: B. The cane provides support to the weak leg. The client holds the cane on
the strong side to widen the base of support .
• Rationale for A: Holding on the weak side causes instability.
• Rationale for C: Cane moves 6-10 inches forward.
• Rationale for D: Dominance is irrelevant; it is about biomechanics.
12. A nurse is preparing a sterile field. Which action causes contamination?
A. Placing the first pack on the table, opening it away from the body.
B. Holding the sterile drape above the waist and elbows close.
C. Adding supplies 1 inch away from the edge of the drape.
D. Reaching across the sterile field to pick up a wrapper.
Correct Answer: D. Reaching over the sterile field violates sterility. Go around the field.
• Rationale for C: The 1-inch border is the only part considered contaminated; adding
supplies away from the edge (i.e., not on the 1-inch border) is fine. The question asks for wrong
action.
13. A client with a hip fracture is using a walker. Which gait pattern is correct?
A. Walker, Right leg, Left leg.
B. Right leg, Left leg, Walker.
C. Walker, Left leg, Right leg.
D. Both legs together, Walker.
Correct Answer: A. The walker is moved first, followed by the affected (weak) leg, then the strong leg.
• Rationale for D: "Swing to" gait is for two crutches, usually not safe for walkers post-surgery.
14. A nurse is applying restraints. How often must the patient be released?
A. Every 1 hour
B. Every 2 hours
C. Every 4 hours
D. Every shift
Correct Answer: B. Every 2 hours for ROM, hydration, and toileting .
AND ANSWERS WITH RATIONALES/ GRADED
A+/100%CORRECT (2026/2027 Edition)
Course: NURS 101
Section 1: Safety & Infection Control (Questions 1-30)
1. A nurse is preparing to insert an NG tube for a client with a bowel obstruction. Which action is most
important to prevent aspiration?
A. Lubricate the tube with water-soluble jelly.
B. Place the client in High-Fowler's position.
C. Instruct the client to tilt their head backward.
D. Have the client take sips of water.
Correct Answer: B. High-Fowler's position (sitting upright at 90 degrees) uses gravity to prevent fluid
from flowing back into the pharynx, reducing the risk of aspiration .
• Rationale for A: Lubricant reduces friction but does not prevent aspiration.
• Rationale for C: Tilting the head back opens the airway but actually increases aspiration risk.
• Rationale for D: Water assists swallowing but is not the primary safety mechanism compared to
positioning.
2. A client is on "Airborne Precautions." Which PPE must the nurse wear when entering the room?
A. Surgical mask
B. N95 respirator mask
C. Gown and gloves only
D. Face shield
Correct Answer: B. Airborne precautions (e.g., TB, Measles, Varicella) require an N95 respirator (or
higher) to filter small airborne particles .
• Rationale for A: Surgical masks protect against Droplet (large particles) only.
• Rationale for C: Required for Contact precautions.
• Rationale for D: Required for procedures with splash risk.
3. A nurse discovers a small fire in a client's trash can. What is the priority action?
A. Pull the fire alarm.
B. Attempt to extinguish the fire.
,C. Evacuate the client.
D. Close the client's door.
Correct Answer: C. RACE: Rescue, Alarm, Confine, Extinguish. Removing the client from immediate
danger is the priority .
• Rationale for A: This happens after rescue.
• Rationale for B: Only attempt if the fire is small and you have been trained (after rescue).
• Rationale for D: Done to contain fire (Confine), but rescue comes first.
4. A client is ordered wrist restraints. Which action indicates proper use?
A. Tie the restraints to the side rail.
B. Apply the restraints tightly to prevent slipping.
C. Tie the restraints using a quick-release knot.
D. Remove the restraints every 4 hours.
Correct Answer: C. A quick-release knot allows for immediate removal in an emergency .
• Rationale for A: Restraints tie to the bed frame (movable part), not the side rail (which lowers).
• Rationale for B: Must allow 1-2 fingers of slack to prevent circulatory damage.
• Rationale for D: Restraints must be removed every 2 hours for ROM and skin check.
5. The nurse is preparing to irrigate a wound. Which step maintains sterile technique?
A. Opening the sterile package away from the body.
B. Holding the bottle of sterile solution upside down to pour.
C. Reaching over the sterile field to grab a gauze.
D. Allowing the solution to flow over the 1-inch border.
Correct Answer: A. The first flap of a sterile package is opened away from the body to prevent the arm
from contaminating the field. The 1-inch border of a sterile field is considered contaminated .
• Rationale for B: Avoid splashing; hold label up so liquid doesn't ruin label, but lid should be
directed away.
• Rationale for C: Never reach over a sterile field; go around.
• Rationale for D: The 1-inch border is contaminated.
6. A nurse is caring for a client with TB. Which type of room pressure is required?
A. Positive pressure
B. Negative pressure
C. Neutral pressure
D. Reverse isolation
Correct Answer: B. Negative pressure prevents air from flowing out into the hallway when the door is
opened, containing the pathogen.
• Rationale for A: Positive pressure is for protective environment (immunocompromised).
, • Rationale for C/D: Not standard for airborne isolation.
7. Which client requires Droplet precautions?
A. Client with C. diff.
B. Client with Meningitis.
C. Client with Scabies.
D. Client with Open wound.
Correct Answer: B. Meningitis (bacterial) is spread via large respiratory droplets .
• Rationale for A & C: Contact precautions (skin/environment).
• Rationale for D: Standard precautions only.
8. The nurse is applying antiembolic stockings (TED hose). Which technique is correct?
A. Roll the stocking down at the top if it is too long.
B. Turn the stocking inside out to the heel before applying.
C. Have the client sit on the side of the bed.
D. Remove the stockings every 72 hours.
Correct Answer: B. Rolling the stocking inside out to the heel allows for easier application and prevents
constrictive wrinkles .
• Rationale for A: Rolling causes a tourniquet effect (DVT risk).
• Rationale for C: Client should be supine to apply (legs elevated).
• Rationale for D: Remove once per shift (q8-12h) for skin assessment.
9. A client falls in the bathroom. What is the nurse's first action?
A. Fill out an incident report.
B. Notify the physician.
C. Assess the client for injury.
D. Move the client back to bed.
Correct Answer: C. Assessment is always first (ABCs). You must determine injuries before moving the
client .
• Rationale for A/D: Documentation and moving occur after assessment.
• Rationale for B: Notify provider after assessment and vitals.
10. Which finding indicates a stage 2 pressure injury?
A. Intact skin with non-blanchable redness.
B. Partial-thickness skin loss with visible dermis.
C. Full-thickness tissue loss with visible bone.
D. Eschar covering the wound bed.
Correct Answer: B. Stage 2 is a break in the skin (blister or shallow ulcer) involving the
epidermis/dermis .
, • Rationale for A: Stage 1.
• Rationale for C: Stage 3 or 4 (SubQ fat exposed is stage 3).
• Rationale for D: Unstageable.
11. When using a cane, the client should hold the cane...
A. On the weak side.
B. On the strong side.
C. 24 inches in front of them.
D. In the dominant hand.
Correct Answer: B. The cane provides support to the weak leg. The client holds the cane on
the strong side to widen the base of support .
• Rationale for A: Holding on the weak side causes instability.
• Rationale for C: Cane moves 6-10 inches forward.
• Rationale for D: Dominance is irrelevant; it is about biomechanics.
12. A nurse is preparing a sterile field. Which action causes contamination?
A. Placing the first pack on the table, opening it away from the body.
B. Holding the sterile drape above the waist and elbows close.
C. Adding supplies 1 inch away from the edge of the drape.
D. Reaching across the sterile field to pick up a wrapper.
Correct Answer: D. Reaching over the sterile field violates sterility. Go around the field.
• Rationale for C: The 1-inch border is the only part considered contaminated; adding
supplies away from the edge (i.e., not on the 1-inch border) is fine. The question asks for wrong
action.
13. A client with a hip fracture is using a walker. Which gait pattern is correct?
A. Walker, Right leg, Left leg.
B. Right leg, Left leg, Walker.
C. Walker, Left leg, Right leg.
D. Both legs together, Walker.
Correct Answer: A. The walker is moved first, followed by the affected (weak) leg, then the strong leg.
• Rationale for D: "Swing to" gait is for two crutches, usually not safe for walkers post-surgery.
14. A nurse is applying restraints. How often must the patient be released?
A. Every 1 hour
B. Every 2 hours
C. Every 4 hours
D. Every shift
Correct Answer: B. Every 2 hours for ROM, hydration, and toileting .
