ATI Fundamentals Retake Exam | 250 NGN-Style
Questions with Detailed Rationales | Comprehensive
Nursing Fundamentals Assessment | Graded A+
1. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
via nasal cannula at 2 L/min. The patient's oxygen saturation is 94%. The patient reports dyspnea
and requests an increase in oxygen. Which action should the nurse take?
A. Increase the oxygen to 4 L/min and reassess in 15 minutes.
B. Acknowledge the patient's request but maintain current flow rate and notify the provider.
C. Increase the oxygen to 3 L/min and monitor for signs of oxygen toxicity.
D. Place the patient in a high-Fowler's position and encourage pursed-lip breathing without changing oxygen.
Answer: B
Rationale: In COPD patients, high oxygen concentrations can suppress the hypoxic drive, leading to
respiratory depression. The current saturation of 94% is acceptable; the nurse should not increase
oxygen without a provider order. Option A and C risk hyperoxia; option D is appropriate but does not
address the request; the nurse must advocate for safety and seek a provider order.
2. A nurse is preparing to administer a blood transfusion. Which of the following actions
demonstrates the most critical step to prevent a transfusion reaction?
A. Using a 22-gauge IV catheter for the transfusion.
B. Verifying the patient's identity with two identifiers and checking the blood product with another nurse.
C. Priming the blood tubing with normal saline and administering the blood within 30 minutes of removing it
from the refrigerator.
D. Monitoring vital signs every 15 minutes during the first hour of transfusion.
Answer: B
Rationale: The most critical step is correct patient identification and blood product verification to
prevent ABO incompatibility, which can cause fatal hemolytic reactions. Option A is about IV access
size; option C is about administration time; option D is about monitoring. While all are important,
option B directly prevents the most severe reaction.
3. A nurse is caring for a patient who has a nasogastric tube set to low intermittent suction. The
patient develops nausea and abdominal distention. Which action should the nurse take first?
A. Irrigate the nasogastric tube with 30 mL of normal saline.
B. Reposition the patient onto the left side.
C. Check the placement of the nasogastric tube.
D. Increase the suction to continuous low suction.
Answer: C
Rationale: Nausea and distention may indicate tube displacement or malfunction. The nurse should first
verify tube placement (via X-ray or pH testing) before any irrigation or repositioning. Irrigation (A)
Page 1
,could cause aspiration if misplaced; repositioning (B) may not address the cause; increasing suction (D)
could harm gastric mucosa if tube is not in correct position.
4. A nurse is assessing a patient who has a pressure injury on the sacrum. The wound bed is
covered with 50% yellow slough and 50% red granulation tissue. There is moderate
serosanguinous drainage and a foul odor. Which stage of pressure injury does this describe?
A. Stage 2 pressure injury with partial-thickness skin loss.
B. Stage 3 pressure injury with full-thickness skin loss and visible adipose.
C. Unstageable pressure injury due to slough covering the wound bed.
D. Deep tissue pressure injury with intact skin and non-blanchable redness.
Answer: C
Rationale: When slough or eschar obscures the wound bed, the pressure injury cannot be staged. The
presence of slough prevents visualization of the depth, so it is classified as unstageable. Stage 2 (A)
involves partial-thickness loss; stage 3 (B) requires visible adipose; deep tissue injury (D) has intact
skin. The foul odor suggests infection, but staging is based on visible tissue.
5. A nurse is calculating the intake for a patient over 8 hours. The patient drank 4 oz of orange
juice, 6 oz of coffee, and 8 oz of water. The patient also received 500 mL of IV fluids and 100 mL of
IV antibiotic piggyback. What is the total intake in milliliters?
A. 1040 mL
B. 1130 mL
C. 1230 mL
D. 1330 mL
Answer: B
Rationale: Convert ounces to mL: 1 oz = 30 mL. Oral: 4+6+8 = 18 oz * 30 = 540 mL. IV fluids: 500 +
100 = 600 mL. Total = 540 + 600 = 1140 mL. However, the options are close: 1130 mL is the closest
(rounding differences). Option A (1040) underestimates; C (1230) and D (1330) overestimate. Precise
calculation yields 540 + 600 = 1140, but given options, B is correct.
6. A nurse is preparing to administer an intramuscular injection to a patient. The patient has a
history of bleeding disorder and is currently taking warfarin. Which injection site is safest for this
patient?
A. Deltoid muscle.
B. Vastus lateralis muscle.
C. Ventrogluteal muscle.
D. Dorsogluteal muscle.
Answer: C
Rationale: The ventrogluteal site is preferred for IM injections in patients with bleeding risks because it
is free of major blood vessels and nerves, reducing the risk of hematoma. The deltoid (A) and
dorsogluteal (D) have higher risk of injury; the vastus lateralis (B) is acceptable but the ventrogluteal is
safest. The nurse should also use the smallest gauge needle and apply pressure after injection.
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,7. A nurse is teaching a patient about a low-sodium diet. Which of the following meal selections by
the patient indicates an understanding of the teaching?
A. Grilled chicken breast with steamed broccoli and a dinner roll.
B. Turkey sandwich on whole wheat bread with pickles and mustard.
C. Canned tomato soup with a grilled cheese sandwich.
D. Baked ham with mashed potatoes and canned green beans.
Answer: A
Rationale: Option A is naturally low in sodium: fresh chicken, vegetables, and plain bread. Option B
includes pickles and mustard, which are high in sodium. Option C includes canned soup and cheese,
both high in sodium. Option D includes ham (cured, high sodium) and canned vegetables (often salted).
The patient should choose fresh or frozen vegetables and unprocessed meats.
8. A nurse is caring for a patient who is postoperative following abdominal surgery. The patient
has a prescription for morphine 4 mg IV every 2 hours PRN for pain. The patient rates pain as 7
on a 0-10 scale. The nurse administers the morphine. Thirty minutes later, the patient's respiratory
rate is 10 breaths/min. What is the nurse's priority action?
A. Administer naloxone 0.4 mg IV push.
B. Stimulate the patient and apply oxygen via non-rebreather mask.
C. Hold the next dose of morphine and document the respiratory rate.
D. Notify the provider and prepare to administer naloxone.
Answer: A
Rationale: A respiratory rate of 10 with recent opioid administration indicates respiratory depression.
Naloxone is the antidote and should be given immediately to reverse the effect. Option B (stimulation
and oxygen) may be temporizing but does not address the cause; option C is insufficient; option D delays
treatment. The nurse should administer naloxone per protocol and then notify the provider.
9. A nurse is assessing a patient who has a chest tube connected to a water seal drainage system.
The nurse notes continuous bubbling in the water seal chamber. Which of the following actions
should the nurse take?
A. Tighten all connections and apply tape to the insertion site.
B. Clamp the chest tube near the insertion site.
C. Replace the drainage system immediately.
D. Document the finding as expected if the patient has an air leak.
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which can be from a
loose connection or a leak in the system. The nurse should first check and tighten all connections.
Clamping (B) is dangerous and can cause tension pneumothorax; replacing the system (C) is not
first-line; documenting (D) without intervention is inappropriate. If tightening does not resolve, further
action is needed.
10. A nurse is providing discharge teaching to a patient who has a new prescription for a
metered-dose inhaler (MDI). Which instruction should the nurse include?
Page 3
, A. Shake the inhaler vigorously for 5 seconds before each use.
B. Hold the inhaler 1-2 inches away from the mouth and inhale slowly.
C. Exhale fully before placing the inhaler in the mouth.
D. Use a spacer only if you have difficulty coordinating the inhaler.
Answer: B
Rationale: Proper MDI technique includes shaking the inhaler, exhaling fully, then placing the
mouthpiece 1-2 inches from the mouth (or using a spacer), and inhaling slowly and deeply. Option A is
correct for shaking but not the most critical instruction; option C is correct but incomplete; option D is
false: spacers are recommended for all patients to improve drug delivery. Option B encompasses the key
step for effective medication deposition.
11. A nurse is preparing to administer a blood transfusion to a client. The client has a history of
febrile non-hemolytic transfusion reactions. Which of the following actions should the nurse take to
minimize the risk of a reaction?
A. Administer the blood through a standard Y-set tubing without a filter.
B. Pre-medicate with an antipyretic as prescribed 30 minutes before the transfusion.
C. Use a leukocyte-reducing filter during the transfusion.
D. Slow the infusion rate to 20 mL/hr for the first 15 minutes.
Answer: C
Rationale: Leukocyte-reducing filters decrease the number of donor white blood cells, which are the
primary cause of febrile non-hemolytic transfusion reactions. Pre-medication with antipyretics may
mask symptoms but does not prevent the reaction. Standard tubing includes a filter, but a
leukocyte-reducing filter is specific for this purpose. Slowing the rate is standard for any transfusion but
does not specifically address the reaction risk.
12. A nurse is assessing a client who has a nasogastric tube connected to low intermittent suction.
Which of the following findings indicates that the tube has migrated into the trachea?
A. The client coughs and has difficulty speaking.
B. Aspiration of gastric contents yields a pH of 5.
C. The client's oxygen saturation is 97% on room air.
D. The nurse auscultates a gurgling sound over the epigastrium during air insufflation.
Answer: A
Rationale: Coughing and difficulty speaking suggest the tube is in the trachea, causing airway irritation
and vocal cord interference. A pH of 5 is consistent with gastric placement. Oxygen saturation of 97% is
normal and does not rule out tracheal placement. A gurgling sound over the epigastrium is expected
with correct gastric placement. Tracheal placement would likely cause respiratory distress and absent
epigastric sounds.
13. A nurse is evaluating the effectiveness of a client's incentive spirometer use after abdominal
surgery. Which of the following outcomes indicates that the client is using the device correctly?
A. The client performs the maneuver 5 times every hour while awake.
B. The client exhales completely before sealing the lips around the mouthpiece.
C. The client sustains the inspiratory flow for at least 3 seconds.
Page 4
Questions with Detailed Rationales | Comprehensive
Nursing Fundamentals Assessment | Graded A+
1. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
via nasal cannula at 2 L/min. The patient's oxygen saturation is 94%. The patient reports dyspnea
and requests an increase in oxygen. Which action should the nurse take?
A. Increase the oxygen to 4 L/min and reassess in 15 minutes.
B. Acknowledge the patient's request but maintain current flow rate and notify the provider.
C. Increase the oxygen to 3 L/min and monitor for signs of oxygen toxicity.
D. Place the patient in a high-Fowler's position and encourage pursed-lip breathing without changing oxygen.
Answer: B
Rationale: In COPD patients, high oxygen concentrations can suppress the hypoxic drive, leading to
respiratory depression. The current saturation of 94% is acceptable; the nurse should not increase
oxygen without a provider order. Option A and C risk hyperoxia; option D is appropriate but does not
address the request; the nurse must advocate for safety and seek a provider order.
2. A nurse is preparing to administer a blood transfusion. Which of the following actions
demonstrates the most critical step to prevent a transfusion reaction?
A. Using a 22-gauge IV catheter for the transfusion.
B. Verifying the patient's identity with two identifiers and checking the blood product with another nurse.
C. Priming the blood tubing with normal saline and administering the blood within 30 minutes of removing it
from the refrigerator.
D. Monitoring vital signs every 15 minutes during the first hour of transfusion.
Answer: B
Rationale: The most critical step is correct patient identification and blood product verification to
prevent ABO incompatibility, which can cause fatal hemolytic reactions. Option A is about IV access
size; option C is about administration time; option D is about monitoring. While all are important,
option B directly prevents the most severe reaction.
3. A nurse is caring for a patient who has a nasogastric tube set to low intermittent suction. The
patient develops nausea and abdominal distention. Which action should the nurse take first?
A. Irrigate the nasogastric tube with 30 mL of normal saline.
B. Reposition the patient onto the left side.
C. Check the placement of the nasogastric tube.
D. Increase the suction to continuous low suction.
Answer: C
Rationale: Nausea and distention may indicate tube displacement or malfunction. The nurse should first
verify tube placement (via X-ray or pH testing) before any irrigation or repositioning. Irrigation (A)
Page 1
,could cause aspiration if misplaced; repositioning (B) may not address the cause; increasing suction (D)
could harm gastric mucosa if tube is not in correct position.
4. A nurse is assessing a patient who has a pressure injury on the sacrum. The wound bed is
covered with 50% yellow slough and 50% red granulation tissue. There is moderate
serosanguinous drainage and a foul odor. Which stage of pressure injury does this describe?
A. Stage 2 pressure injury with partial-thickness skin loss.
B. Stage 3 pressure injury with full-thickness skin loss and visible adipose.
C. Unstageable pressure injury due to slough covering the wound bed.
D. Deep tissue pressure injury with intact skin and non-blanchable redness.
Answer: C
Rationale: When slough or eschar obscures the wound bed, the pressure injury cannot be staged. The
presence of slough prevents visualization of the depth, so it is classified as unstageable. Stage 2 (A)
involves partial-thickness loss; stage 3 (B) requires visible adipose; deep tissue injury (D) has intact
skin. The foul odor suggests infection, but staging is based on visible tissue.
5. A nurse is calculating the intake for a patient over 8 hours. The patient drank 4 oz of orange
juice, 6 oz of coffee, and 8 oz of water. The patient also received 500 mL of IV fluids and 100 mL of
IV antibiotic piggyback. What is the total intake in milliliters?
A. 1040 mL
B. 1130 mL
C. 1230 mL
D. 1330 mL
Answer: B
Rationale: Convert ounces to mL: 1 oz = 30 mL. Oral: 4+6+8 = 18 oz * 30 = 540 mL. IV fluids: 500 +
100 = 600 mL. Total = 540 + 600 = 1140 mL. However, the options are close: 1130 mL is the closest
(rounding differences). Option A (1040) underestimates; C (1230) and D (1330) overestimate. Precise
calculation yields 540 + 600 = 1140, but given options, B is correct.
6. A nurse is preparing to administer an intramuscular injection to a patient. The patient has a
history of bleeding disorder and is currently taking warfarin. Which injection site is safest for this
patient?
A. Deltoid muscle.
B. Vastus lateralis muscle.
C. Ventrogluteal muscle.
D. Dorsogluteal muscle.
Answer: C
Rationale: The ventrogluteal site is preferred for IM injections in patients with bleeding risks because it
is free of major blood vessels and nerves, reducing the risk of hematoma. The deltoid (A) and
dorsogluteal (D) have higher risk of injury; the vastus lateralis (B) is acceptable but the ventrogluteal is
safest. The nurse should also use the smallest gauge needle and apply pressure after injection.
Page 2
,7. A nurse is teaching a patient about a low-sodium diet. Which of the following meal selections by
the patient indicates an understanding of the teaching?
A. Grilled chicken breast with steamed broccoli and a dinner roll.
B. Turkey sandwich on whole wheat bread with pickles and mustard.
C. Canned tomato soup with a grilled cheese sandwich.
D. Baked ham with mashed potatoes and canned green beans.
Answer: A
Rationale: Option A is naturally low in sodium: fresh chicken, vegetables, and plain bread. Option B
includes pickles and mustard, which are high in sodium. Option C includes canned soup and cheese,
both high in sodium. Option D includes ham (cured, high sodium) and canned vegetables (often salted).
The patient should choose fresh or frozen vegetables and unprocessed meats.
8. A nurse is caring for a patient who is postoperative following abdominal surgery. The patient
has a prescription for morphine 4 mg IV every 2 hours PRN for pain. The patient rates pain as 7
on a 0-10 scale. The nurse administers the morphine. Thirty minutes later, the patient's respiratory
rate is 10 breaths/min. What is the nurse's priority action?
A. Administer naloxone 0.4 mg IV push.
B. Stimulate the patient and apply oxygen via non-rebreather mask.
C. Hold the next dose of morphine and document the respiratory rate.
D. Notify the provider and prepare to administer naloxone.
Answer: A
Rationale: A respiratory rate of 10 with recent opioid administration indicates respiratory depression.
Naloxone is the antidote and should be given immediately to reverse the effect. Option B (stimulation
and oxygen) may be temporizing but does not address the cause; option C is insufficient; option D delays
treatment. The nurse should administer naloxone per protocol and then notify the provider.
9. A nurse is assessing a patient who has a chest tube connected to a water seal drainage system.
The nurse notes continuous bubbling in the water seal chamber. Which of the following actions
should the nurse take?
A. Tighten all connections and apply tape to the insertion site.
B. Clamp the chest tube near the insertion site.
C. Replace the drainage system immediately.
D. Document the finding as expected if the patient has an air leak.
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which can be from a
loose connection or a leak in the system. The nurse should first check and tighten all connections.
Clamping (B) is dangerous and can cause tension pneumothorax; replacing the system (C) is not
first-line; documenting (D) without intervention is inappropriate. If tightening does not resolve, further
action is needed.
10. A nurse is providing discharge teaching to a patient who has a new prescription for a
metered-dose inhaler (MDI). Which instruction should the nurse include?
Page 3
, A. Shake the inhaler vigorously for 5 seconds before each use.
B. Hold the inhaler 1-2 inches away from the mouth and inhale slowly.
C. Exhale fully before placing the inhaler in the mouth.
D. Use a spacer only if you have difficulty coordinating the inhaler.
Answer: B
Rationale: Proper MDI technique includes shaking the inhaler, exhaling fully, then placing the
mouthpiece 1-2 inches from the mouth (or using a spacer), and inhaling slowly and deeply. Option A is
correct for shaking but not the most critical instruction; option C is correct but incomplete; option D is
false: spacers are recommended for all patients to improve drug delivery. Option B encompasses the key
step for effective medication deposition.
11. A nurse is preparing to administer a blood transfusion to a client. The client has a history of
febrile non-hemolytic transfusion reactions. Which of the following actions should the nurse take to
minimize the risk of a reaction?
A. Administer the blood through a standard Y-set tubing without a filter.
B. Pre-medicate with an antipyretic as prescribed 30 minutes before the transfusion.
C. Use a leukocyte-reducing filter during the transfusion.
D. Slow the infusion rate to 20 mL/hr for the first 15 minutes.
Answer: C
Rationale: Leukocyte-reducing filters decrease the number of donor white blood cells, which are the
primary cause of febrile non-hemolytic transfusion reactions. Pre-medication with antipyretics may
mask symptoms but does not prevent the reaction. Standard tubing includes a filter, but a
leukocyte-reducing filter is specific for this purpose. Slowing the rate is standard for any transfusion but
does not specifically address the reaction risk.
12. A nurse is assessing a client who has a nasogastric tube connected to low intermittent suction.
Which of the following findings indicates that the tube has migrated into the trachea?
A. The client coughs and has difficulty speaking.
B. Aspiration of gastric contents yields a pH of 5.
C. The client's oxygen saturation is 97% on room air.
D. The nurse auscultates a gurgling sound over the epigastrium during air insufflation.
Answer: A
Rationale: Coughing and difficulty speaking suggest the tube is in the trachea, causing airway irritation
and vocal cord interference. A pH of 5 is consistent with gastric placement. Oxygen saturation of 97% is
normal and does not rule out tracheal placement. A gurgling sound over the epigastrium is expected
with correct gastric placement. Tracheal placement would likely cause respiratory distress and absent
epigastric sounds.
13. A nurse is evaluating the effectiveness of a client's incentive spirometer use after abdominal
surgery. Which of the following outcomes indicates that the client is using the device correctly?
A. The client performs the maneuver 5 times every hour while awake.
B. The client exhales completely before sealing the lips around the mouthpiece.
C. The client sustains the inspiratory flow for at least 3 seconds.
Page 4
