ATI Fundamentals Proctored Exam
Test Bank 2025 2025 update
EXAM
1. A nurse is preparing to insert a nasogastric (NG) tube for a
client who is alert and oriented. Which of the following
actions should the nurse take first?
A) Measure the length of the tube from the tip of the nose to
the earlobe to the xiphoid process.
B) Lubricate the tip of the tube with water-soluble jelly.
C) Place the client in a high-Fowler's position.
D) Explain the procedure to the client in detail.
Answer: D
Rationale: For an alert and oriented client, the nurse must first
obtain informed consent and provide a thorough explanation of
the procedure to reduce anxiety and promote cooperation. While
positioning (C), measuring (A), and lubricating (B) are important
steps, they occur after the client understands the procedure and
agrees. The order of priority is "assess/educate" before
"implement."
Client Need: Psychosocial Integrity / Basic Care and Comfort.
2. A nurse is caring for a client who has an indwelling urinary
catheter. Which of the following actions is most important to
prevent catheter-associated urinary tract infection (CAUTI)?
, A) Empty the drainage bag every 8 hours.
B) Secure the catheter tubing to the client's thigh.
C) Perform perineal care with soap and water twice daily.
D) Maintain the closed drainage system integrity.
Answer: D
Rationale: The single most effective intervention to prevent
CAUTI is maintaining a sterile, closed drainage system. Breaking
the closed system (e.g., for irrigations or disconnecting the tubing)
introduces bacteria. While securing the tubing (B) prevents trauma
and perineal care (C) reduces bacterial load, maintaining the
closed system is the priority for infection prevention. Emptying
the bag (A) should be done when full (usually every 8 hours or
prn), but it is not the most critical preventative action.
Client Need: Safety and Infection Control.
3. A nurse is calculating the intake for a client from 0700 to
1500. The client consumed 4 oz of juice, 10 oz of coffee, 6 oz
of broth, and 12 oz of water. How many mL should the nurse
document? (Round to the nearest whole number.)
A) 960 mL
B) 480 mL
C) 800 mL
D) 720 mL
Answer: A
Rationale: Convert ounces to mL (1 oz = 30 mL). Total ounces = 4
+ 10 + 6 + 12 = 32 oz. 32 oz x 30 mL = 960 mL. Remember that
,intake includes all oral liquids (juice, coffee, broth, water). Ice chips
are typically recorded as half their volume, but that is not in this
scenario.
Client Need: Basic Care and Comfort (Fluid Balance).
4. A nurse is preparing to administer an intramuscular (IM)
injection to an adult client in the ventrogluteal site. Which of
the following actions should the nurse take?
A) Use a 22-gauge, 1-inch needle.
B) Place the client in a supine position with toes pointing
inward.
C) Use the Z-track technique to displace the skin laterally.
D) Aspirate for 5 to 10 seconds before injecting.
Answer: C
Rationale: The Z-track technique is recommended for IM
injections (especially for irritating medications) to prevent tracking
of medication through subcutaneous tissue and to seal the
medication in the muscle. For the ventrogluteal site, the client is
positioned on the side or supine with the knee flexed (not toes
pointed inward, B). Needle length for an adult IM is usually 1 to
1.5 inches (A is too short for ventrogluteal in an average adult; 1.5
inches is preferred). Current evidence suggests aspiration is no
longer routinely recommended for IM injections (D is outdated).
Client Need: Pharmacological and Parenteral Therapies.
, 5. A nurse is performing a skin assessment on an older adult
client. Which of the following findings is an expected age-
related change?
A) Thickening of the epidermis.
B) Decreased skin elasticity and turgor.
C) Increased number of sweat glands.
D) Increased subcutaneous fat distribution.
Answer: B
Rationale: Older adults experience decreased skin elasticity and
turgor due to loss of collagen and elastin. The epidermis actually
thins (not thickens, A), the number of sweat glands decreases (not
increases, C), and subcutaneous fat diminishes (not increases, D),
making older adults more prone to hypothermia and skin
breakdown.
Client Need: Health Promotion and Maintenance.
6. A nurse is caring for a client who is receiving continuous
enteral tube feedings. Which of the following actions should
the nurse take to reduce the risk of aspiration?
A) Flush the tubing with 30 mL of water every 4 hours.
B) Keep the head of the bed elevated to 30° to 45°.
C) Change the feeding bag every 72 hours.
D) Check gastric residual volumes every 12 hours.
Answer: B
Rationale: Keeping the head of the bed elevated to 30° to 45°
Test Bank 2025 2025 update
EXAM
1. A nurse is preparing to insert a nasogastric (NG) tube for a
client who is alert and oriented. Which of the following
actions should the nurse take first?
A) Measure the length of the tube from the tip of the nose to
the earlobe to the xiphoid process.
B) Lubricate the tip of the tube with water-soluble jelly.
C) Place the client in a high-Fowler's position.
D) Explain the procedure to the client in detail.
Answer: D
Rationale: For an alert and oriented client, the nurse must first
obtain informed consent and provide a thorough explanation of
the procedure to reduce anxiety and promote cooperation. While
positioning (C), measuring (A), and lubricating (B) are important
steps, they occur after the client understands the procedure and
agrees. The order of priority is "assess/educate" before
"implement."
Client Need: Psychosocial Integrity / Basic Care and Comfort.
2. A nurse is caring for a client who has an indwelling urinary
catheter. Which of the following actions is most important to
prevent catheter-associated urinary tract infection (CAUTI)?
, A) Empty the drainage bag every 8 hours.
B) Secure the catheter tubing to the client's thigh.
C) Perform perineal care with soap and water twice daily.
D) Maintain the closed drainage system integrity.
Answer: D
Rationale: The single most effective intervention to prevent
CAUTI is maintaining a sterile, closed drainage system. Breaking
the closed system (e.g., for irrigations or disconnecting the tubing)
introduces bacteria. While securing the tubing (B) prevents trauma
and perineal care (C) reduces bacterial load, maintaining the
closed system is the priority for infection prevention. Emptying
the bag (A) should be done when full (usually every 8 hours or
prn), but it is not the most critical preventative action.
Client Need: Safety and Infection Control.
3. A nurse is calculating the intake for a client from 0700 to
1500. The client consumed 4 oz of juice, 10 oz of coffee, 6 oz
of broth, and 12 oz of water. How many mL should the nurse
document? (Round to the nearest whole number.)
A) 960 mL
B) 480 mL
C) 800 mL
D) 720 mL
Answer: A
Rationale: Convert ounces to mL (1 oz = 30 mL). Total ounces = 4
+ 10 + 6 + 12 = 32 oz. 32 oz x 30 mL = 960 mL. Remember that
,intake includes all oral liquids (juice, coffee, broth, water). Ice chips
are typically recorded as half their volume, but that is not in this
scenario.
Client Need: Basic Care and Comfort (Fluid Balance).
4. A nurse is preparing to administer an intramuscular (IM)
injection to an adult client in the ventrogluteal site. Which of
the following actions should the nurse take?
A) Use a 22-gauge, 1-inch needle.
B) Place the client in a supine position with toes pointing
inward.
C) Use the Z-track technique to displace the skin laterally.
D) Aspirate for 5 to 10 seconds before injecting.
Answer: C
Rationale: The Z-track technique is recommended for IM
injections (especially for irritating medications) to prevent tracking
of medication through subcutaneous tissue and to seal the
medication in the muscle. For the ventrogluteal site, the client is
positioned on the side or supine with the knee flexed (not toes
pointed inward, B). Needle length for an adult IM is usually 1 to
1.5 inches (A is too short for ventrogluteal in an average adult; 1.5
inches is preferred). Current evidence suggests aspiration is no
longer routinely recommended for IM injections (D is outdated).
Client Need: Pharmacological and Parenteral Therapies.
, 5. A nurse is performing a skin assessment on an older adult
client. Which of the following findings is an expected age-
related change?
A) Thickening of the epidermis.
B) Decreased skin elasticity and turgor.
C) Increased number of sweat glands.
D) Increased subcutaneous fat distribution.
Answer: B
Rationale: Older adults experience decreased skin elasticity and
turgor due to loss of collagen and elastin. The epidermis actually
thins (not thickens, A), the number of sweat glands decreases (not
increases, C), and subcutaneous fat diminishes (not increases, D),
making older adults more prone to hypothermia and skin
breakdown.
Client Need: Health Promotion and Maintenance.
6. A nurse is caring for a client who is receiving continuous
enteral tube feedings. Which of the following actions should
the nurse take to reduce the risk of aspiration?
A) Flush the tubing with 30 mL of water every 4 hours.
B) Keep the head of the bed elevated to 30° to 45°.
C) Change the feeding bag every 72 hours.
D) Check gastric residual volumes every 12 hours.
Answer: B
Rationale: Keeping the head of the bed elevated to 30° to 45°
