NURS 325ATI FUNDAMENTALS NURSING FOUNDATIONS QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client who has a prescription for restraints. Which of the following actions
should the nurse take?
A. Renew the restraint prescription every 48 hours.
B. Ensure that two fingers can fit between the restraint and the client's skin.
C. Attach the restraint straps to the side rails of the bed.
D. Request the client's family to sign the consent form for the restraints.
🟢 B. Ensure that two fingers can fit between the restraint and the client's skin.
🔴 RATIONALE: To prevent neurovascular injury, the nurse must ensure the restraint is not too
tight, allowing space for two fingers to fit between the restraint and the client.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the
following actions should the nurse take to prevent a deep vein thrombosis (DVT)?
A. Encourage the client to remain on bed rest for 48 hours.
B. Apply sequential compression devices (SCDs) to the client's legs.
C. Place a pillow under the client's knees to promote comfort.
D. Massage the client's calves to promote circulation.
🟢 B. Apply sequential compression devices (SCDs) to the client's legs.
🔴 RATIONALE: SCDs promote venous return and prevent stasis, which are primary methods for
preventing DVT in immobile postoperative clients.
A nurse is preparing to administer medications to a client. Which of the following actions
demonstrates the nurse's understanding of the "right route" safety standard?
A. Asking the client to swallow a pill that was prescribed for sublingual administration.
B. Crushing an extended-release tablet because the client has difficulty swallowing.
,C. Verifying the medication order specifies the intended route of administration.
D. Using a different route than prescribed if the client refuses to take it orally.
🟢 C. Verifying the medication order specifies the intended route of administration.
🔴 RATIONALE: The nurse must always follow the provider's order regarding the route of
administration to ensure safety and therapeutic effect.
A nurse is performing a physical assessment on a client. Which of the following findings should the
nurse report to the provider immediately?
A. Capillary refill of 2 seconds.
B. Respiratory rate of 18/min.
C. Oxygen saturation of 88% on room air.
D. Heart rate of 78/min.
🟢 C. Oxygen saturation of 88% on room air.
🔴 RATIONALE: An oxygen saturation of 88% is below the normal range of 95%–100% and
indicates hypoxemia, requiring immediate intervention.
A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following
items should the nurse include on the client's meal tray?
A. Plain gelatin.
B. Milk.
C. Tomato soup.
D. Vanilla ice cream.
🟢 A. Plain gelatin.
🔴 RATIONALE: A clear liquid diet includes foods that are transparent and liquid at room
temperature, such as plain gelatin, broth, and tea.
,A nurse is providing teaching to a client about hand hygiene. Which of the following statements by
the client indicates an understanding of the teaching?
A. I should use alcohol-based hand rub if my hands are visibly soiled.
B. I should wash my hands for at least 15 seconds after contact with a client.
C. I should use hot water to kill all bacteria on my hands.
D. I should dry my hands using a cloth towel kept in the bathroom.
🟢 B. I should wash my hands for at least 15 seconds after contact with a client.
🔴 RATIONALE: Washing hands with soap and water for at least 15–20 seconds is recommended
to effectively remove microorganisms.
A nurse is planning care for a client who is at high risk for falls. Which of the following interventions
should the nurse include in the plan?
A. Keep the bed in the highest position.
B. Place the client in a room far from the nurses' station.
C. Ensure the client's call light is within reach.
D. Encourage the client to wear loose-fitting slippers.
🟢 C. Ensure the client's call light is within reach.
🔴 RATIONALE: Providing the client with a way to summon assistance minimizes the need for the
client to get up unassisted, thereby reducing fall risk.
A nurse is assessing a client's wound and notes a small amount of serosanguineous drainage.
How should the nurse document this finding?
A. Drainage is thick and purulent.
B. Drainage is yellow and viscous.
C. Drainage is thin, watery, and pale red.
D. Drainage is bright red and indicates hemorrhage.
🟢 C. Drainage is thin, watery, and pale red.
, 🔴 RATIONALE: Serosanguineous drainage is a mixture of serum (watery/clear) and blood
(red/pink), resulting in a thin, pale red appearance.
A nurse is teaching a client about the use of an incentive spirometer. Which of the following
instructions should the nurse provide?
A. Exhale forcefully into the mouthpiece.
B. Inhale slowly and deeply to raise the indicator.
C. Use the device once every 24 hours.
D. Take a quick breath to ensure the piston rises rapidly.
🟢 B. Inhale slowly and deeply to raise the indicator.
🔴 RATIONALE: The incentive spirometer is used to encourage deep breathing; a slow, sustained
inhalation is required to expand the alveoli.
A nurse is caring for a client who has a pressure injury. Which of the following interventions is
appropriate to promote healing?
A. Maintain a moist wound environment.
B. Clean the wound with hydrogen peroxide.
C. Keep the wound open to the air at all times.
D. Apply a heat lamp to the wound area.
🟢 A. Maintain a moist wound environment.
🔴 RATIONALE: A moist wound environment promotes epithelialization and healing compared to a
dry, crusted environment.
A nurse is preparing to transfer a client from the bed to a chair. Which of the following actions
should the nurse take first?
A. Lower the bed to its lowest position.
B. Assess the client's ability to help with the transfer.
C. Place the chair on the client's weaker side.
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client who has a prescription for restraints. Which of the following actions
should the nurse take?
A. Renew the restraint prescription every 48 hours.
B. Ensure that two fingers can fit between the restraint and the client's skin.
C. Attach the restraint straps to the side rails of the bed.
D. Request the client's family to sign the consent form for the restraints.
🟢 B. Ensure that two fingers can fit between the restraint and the client's skin.
🔴 RATIONALE: To prevent neurovascular injury, the nurse must ensure the restraint is not too
tight, allowing space for two fingers to fit between the restraint and the client.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the
following actions should the nurse take to prevent a deep vein thrombosis (DVT)?
A. Encourage the client to remain on bed rest for 48 hours.
B. Apply sequential compression devices (SCDs) to the client's legs.
C. Place a pillow under the client's knees to promote comfort.
D. Massage the client's calves to promote circulation.
🟢 B. Apply sequential compression devices (SCDs) to the client's legs.
🔴 RATIONALE: SCDs promote venous return and prevent stasis, which are primary methods for
preventing DVT in immobile postoperative clients.
A nurse is preparing to administer medications to a client. Which of the following actions
demonstrates the nurse's understanding of the "right route" safety standard?
A. Asking the client to swallow a pill that was prescribed for sublingual administration.
B. Crushing an extended-release tablet because the client has difficulty swallowing.
,C. Verifying the medication order specifies the intended route of administration.
D. Using a different route than prescribed if the client refuses to take it orally.
🟢 C. Verifying the medication order specifies the intended route of administration.
🔴 RATIONALE: The nurse must always follow the provider's order regarding the route of
administration to ensure safety and therapeutic effect.
A nurse is performing a physical assessment on a client. Which of the following findings should the
nurse report to the provider immediately?
A. Capillary refill of 2 seconds.
B. Respiratory rate of 18/min.
C. Oxygen saturation of 88% on room air.
D. Heart rate of 78/min.
🟢 C. Oxygen saturation of 88% on room air.
🔴 RATIONALE: An oxygen saturation of 88% is below the normal range of 95%–100% and
indicates hypoxemia, requiring immediate intervention.
A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following
items should the nurse include on the client's meal tray?
A. Plain gelatin.
B. Milk.
C. Tomato soup.
D. Vanilla ice cream.
🟢 A. Plain gelatin.
🔴 RATIONALE: A clear liquid diet includes foods that are transparent and liquid at room
temperature, such as plain gelatin, broth, and tea.
,A nurse is providing teaching to a client about hand hygiene. Which of the following statements by
the client indicates an understanding of the teaching?
A. I should use alcohol-based hand rub if my hands are visibly soiled.
B. I should wash my hands for at least 15 seconds after contact with a client.
C. I should use hot water to kill all bacteria on my hands.
D. I should dry my hands using a cloth towel kept in the bathroom.
🟢 B. I should wash my hands for at least 15 seconds after contact with a client.
🔴 RATIONALE: Washing hands with soap and water for at least 15–20 seconds is recommended
to effectively remove microorganisms.
A nurse is planning care for a client who is at high risk for falls. Which of the following interventions
should the nurse include in the plan?
A. Keep the bed in the highest position.
B. Place the client in a room far from the nurses' station.
C. Ensure the client's call light is within reach.
D. Encourage the client to wear loose-fitting slippers.
🟢 C. Ensure the client's call light is within reach.
🔴 RATIONALE: Providing the client with a way to summon assistance minimizes the need for the
client to get up unassisted, thereby reducing fall risk.
A nurse is assessing a client's wound and notes a small amount of serosanguineous drainage.
How should the nurse document this finding?
A. Drainage is thick and purulent.
B. Drainage is yellow and viscous.
C. Drainage is thin, watery, and pale red.
D. Drainage is bright red and indicates hemorrhage.
🟢 C. Drainage is thin, watery, and pale red.
, 🔴 RATIONALE: Serosanguineous drainage is a mixture of serum (watery/clear) and blood
(red/pink), resulting in a thin, pale red appearance.
A nurse is teaching a client about the use of an incentive spirometer. Which of the following
instructions should the nurse provide?
A. Exhale forcefully into the mouthpiece.
B. Inhale slowly and deeply to raise the indicator.
C. Use the device once every 24 hours.
D. Take a quick breath to ensure the piston rises rapidly.
🟢 B. Inhale slowly and deeply to raise the indicator.
🔴 RATIONALE: The incentive spirometer is used to encourage deep breathing; a slow, sustained
inhalation is required to expand the alveoli.
A nurse is caring for a client who has a pressure injury. Which of the following interventions is
appropriate to promote healing?
A. Maintain a moist wound environment.
B. Clean the wound with hydrogen peroxide.
C. Keep the wound open to the air at all times.
D. Apply a heat lamp to the wound area.
🟢 A. Maintain a moist wound environment.
🔴 RATIONALE: A moist wound environment promotes epithelialization and healing compared to a
dry, crusted environment.
A nurse is preparing to transfer a client from the bed to a chair. Which of the following actions
should the nurse take first?
A. Lower the bed to its lowest position.
B. Assess the client's ability to help with the transfer.
C. Place the chair on the client's weaker side.
