**Foundations of Care: A Comprehensive ATI
RN Fundamentals Proctored Exam (NGN) with
Rationales**
---
**Question 1**
A nurse is planning care for a client who is on bed rest. Which of the following actions should the nurse
take to prevent the development of a deep-vein thrombosis (DVT)?
A. Massage the client’s calves every 2 hours.
B. Place pillows under the client’s knees.
C. Apply sequential compression devices (SCDs).
D. Restrict fluid intake to 1.5 L per day.
💫RATIONALE✔️✔️: SCDs promote venous return by mechanically compressing the deep veins of the legs,
reducing venous stasis and the risk of DVT. Massage can dislodge an existing clot. Pillows under the
knees can cause venous pooling. Adequate hydration (not restriction) is needed to prevent
hemoconcentration.
💫ANSWER✔️✔️: C. Apply sequential compression devices (SCDs).
---
**Question 2**
A nurse is reinforcing teaching with a client about how to perform blood glucose monitoring at home.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I will use the first drop of blood from my fingertip."
B. "I will cleanse the site with an alcohol swab and test immediately."
,C. "I will puncture the side of my fingertip, not the center."
D. "I will hold my hand below my waist to increase blood flow."
💫RATIONALE✔️✔️: Puncturing the side of the fingertip is less painful and provides adequate blood flow.
The first drop should be wiped away to avoid contamination with tissue fluid. The site should be dry
after alcohol (allow to dry) to prevent inaccurate readings or stinging. Holding the hand down can help
but is not necessary; the side puncture is key.
💫ANSWER✔️✔️: C. "I will puncture the side of my fingertip, not the center."
---
**Question 3**
A nurse is caring for a client who has a new prescription for a low-residue diet. Which of the following
food items should the nurse remove from the client’s breakfast tray?
A. Scrambled eggs
B. White toast with butter
C. Whole-grain oatmeal
D. Strained apple juice
💫RATIONALE✔️✔️: A low-residue diet limits high-fiber foods. Whole-grain oatmeal is high in fiber.
Scrambled eggs, white toast, and strained juice (no pulp) are allowed on a low-residue diet.
💫ANSWER✔️✔️: C. Whole-grain oatmeal
---
**Question 4**
A nurse is performing a manual blood pressure measurement. The nurse inflates the cuff to 180 mmHg
and notes the first Korotkoff sound at 130 mmHg. The sound disappears at 80 mmHg. Which of the
following represents the correct systolic and diastolic pressures?
A. 180/130
B. 130/80
,C. 180/80
D. 130/0
💫RATIONALE✔️✔️: Systolic pressure is the first appearance of a tapping sound (Korotkoff phase I).
Diastolic pressure in adults is the point at which the sound disappears (phase V). The inflation pressure
(180) is not recorded.
💫ANSWER✔️✔️: B. 130/80
---
**Question 5**
A nurse is preparing to remove a client’s peripheral IV catheter. Which of the following actions should
the nurse take first?
A. Clamp the IV tubing.
B. Remove the transparent dressing.
C. Stop the infusion.
D. Apply pressure to the site with sterile gauze.
💫RATIONALE✔️✔️: The first step is to stop the infusion to prevent further fluid or medication from
entering as the catheter is removed. Then the nurse clamps the tubing, removes the dressing, and
withdraws the catheter.
💫ANSWER✔️✔️: C. Stop the infusion.
---
**Question 6**
A nurse is assessing a client’s respiratory status. The client breathes in deeply for 3 seconds, holds it for
1 second, and exhales slowly for 4 seconds. Which of the following terms describes this breathing
pattern?
A. Kussmaul breathing
B. Cheyne-Stokes respiration
, C. Pursed-lip breathing
D. Biot’s respiration
💫RATIONALE✔️✔️: Pursed-lip breathing involves prolonged expiration, often used by clients with COPD
to prevent airway collapse. Kussmaul is deep, rapid breathing (acidosis). Cheyne-Stokes is cyclical with
apneic periods. Biot’s is irregular with variable depth.
💫ANSWER✔️✔️: C. Pursed-lip breathing
---
**Question 7**
A nurse is administering an enteral feeding via a gastrostomy tube. The client reports feeling nauseated.
Which of the following actions should the nurse take?
A. Flush the tube with 50 mL of cold water.
B. Increase the infusion rate to complete feeding faster.
C. Check the gastric residual volume.
D. Position the client supine.
💫RATIONALE✔️✔️: Nausea can indicate delayed gastric emptying. The nurse should check the residual
volume. If high, the feeding may need to be held. Flushing with cold water can cause cramps. Supine
position increases aspiration risk.
💫ANSWER✔️✔️: C. Check the gastric residual volume.
---
**Question 8**
A nurse is reinforcing teaching with a client who has a new diagnosis of a seizure disorder and a
prescription for phenytoin (Dilantin). Which of the following statements by the client indicates
understanding?
A. "I will take this medication with food to prevent stomach upset."
B. "I will brush my teeth gently with a soft-bristled toothbrush."
RN Fundamentals Proctored Exam (NGN) with
Rationales**
---
**Question 1**
A nurse is planning care for a client who is on bed rest. Which of the following actions should the nurse
take to prevent the development of a deep-vein thrombosis (DVT)?
A. Massage the client’s calves every 2 hours.
B. Place pillows under the client’s knees.
C. Apply sequential compression devices (SCDs).
D. Restrict fluid intake to 1.5 L per day.
💫RATIONALE✔️✔️: SCDs promote venous return by mechanically compressing the deep veins of the legs,
reducing venous stasis and the risk of DVT. Massage can dislodge an existing clot. Pillows under the
knees can cause venous pooling. Adequate hydration (not restriction) is needed to prevent
hemoconcentration.
💫ANSWER✔️✔️: C. Apply sequential compression devices (SCDs).
---
**Question 2**
A nurse is reinforcing teaching with a client about how to perform blood glucose monitoring at home.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I will use the first drop of blood from my fingertip."
B. "I will cleanse the site with an alcohol swab and test immediately."
,C. "I will puncture the side of my fingertip, not the center."
D. "I will hold my hand below my waist to increase blood flow."
💫RATIONALE✔️✔️: Puncturing the side of the fingertip is less painful and provides adequate blood flow.
The first drop should be wiped away to avoid contamination with tissue fluid. The site should be dry
after alcohol (allow to dry) to prevent inaccurate readings or stinging. Holding the hand down can help
but is not necessary; the side puncture is key.
💫ANSWER✔️✔️: C. "I will puncture the side of my fingertip, not the center."
---
**Question 3**
A nurse is caring for a client who has a new prescription for a low-residue diet. Which of the following
food items should the nurse remove from the client’s breakfast tray?
A. Scrambled eggs
B. White toast with butter
C. Whole-grain oatmeal
D. Strained apple juice
💫RATIONALE✔️✔️: A low-residue diet limits high-fiber foods. Whole-grain oatmeal is high in fiber.
Scrambled eggs, white toast, and strained juice (no pulp) are allowed on a low-residue diet.
💫ANSWER✔️✔️: C. Whole-grain oatmeal
---
**Question 4**
A nurse is performing a manual blood pressure measurement. The nurse inflates the cuff to 180 mmHg
and notes the first Korotkoff sound at 130 mmHg. The sound disappears at 80 mmHg. Which of the
following represents the correct systolic and diastolic pressures?
A. 180/130
B. 130/80
,C. 180/80
D. 130/0
💫RATIONALE✔️✔️: Systolic pressure is the first appearance of a tapping sound (Korotkoff phase I).
Diastolic pressure in adults is the point at which the sound disappears (phase V). The inflation pressure
(180) is not recorded.
💫ANSWER✔️✔️: B. 130/80
---
**Question 5**
A nurse is preparing to remove a client’s peripheral IV catheter. Which of the following actions should
the nurse take first?
A. Clamp the IV tubing.
B. Remove the transparent dressing.
C. Stop the infusion.
D. Apply pressure to the site with sterile gauze.
💫RATIONALE✔️✔️: The first step is to stop the infusion to prevent further fluid or medication from
entering as the catheter is removed. Then the nurse clamps the tubing, removes the dressing, and
withdraws the catheter.
💫ANSWER✔️✔️: C. Stop the infusion.
---
**Question 6**
A nurse is assessing a client’s respiratory status. The client breathes in deeply for 3 seconds, holds it for
1 second, and exhales slowly for 4 seconds. Which of the following terms describes this breathing
pattern?
A. Kussmaul breathing
B. Cheyne-Stokes respiration
, C. Pursed-lip breathing
D. Biot’s respiration
💫RATIONALE✔️✔️: Pursed-lip breathing involves prolonged expiration, often used by clients with COPD
to prevent airway collapse. Kussmaul is deep, rapid breathing (acidosis). Cheyne-Stokes is cyclical with
apneic periods. Biot’s is irregular with variable depth.
💫ANSWER✔️✔️: C. Pursed-lip breathing
---
**Question 7**
A nurse is administering an enteral feeding via a gastrostomy tube. The client reports feeling nauseated.
Which of the following actions should the nurse take?
A. Flush the tube with 50 mL of cold water.
B. Increase the infusion rate to complete feeding faster.
C. Check the gastric residual volume.
D. Position the client supine.
💫RATIONALE✔️✔️: Nausea can indicate delayed gastric emptying. The nurse should check the residual
volume. If high, the feeding may need to be held. Flushing with cold water can cause cramps. Supine
position increases aspiration risk.
💫ANSWER✔️✔️: C. Check the gastric residual volume.
---
**Question 8**
A nurse is reinforcing teaching with a client who has a new diagnosis of a seizure disorder and a
prescription for phenytoin (Dilantin). Which of the following statements by the client indicates
understanding?
A. "I will take this medication with food to prevent stomach upset."
B. "I will brush my teeth gently with a soft-bristled toothbrush."
