ATI Fundamentals
CMS Proctored Exam Study Guide
Questions & Answers with Rationales
A Comprehensive Review Covering the Nursing Process, Vital Signs, Infection
Control, Safety, Hygiene & Skin Integrity, Mobility, Nutrition & Fluids,
Elimination, Oxygenation, Medication Administration, Wound Care,
Perioperative Care, Pain Management, Communication & Legal/Ethical
Practice, and End-of-Life Care
, 1. Nursing Process & Clinical Judgment
Q1. A nurse is developing a plan of care for a newly admitted client.
Which step of the nursing process should the nurse complete first?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale:
Assessment is the first step of the nursing process; the nurse must collect
subjective and objective data before a nursing diagnosis, plan, interventions,
or evaluation can occur.
Q2. Which nursing action best reflects the 'implementation' phase of the
nursing process?
A. Collecting a health history
B. Identifying priority nursing diagnoses
C. Administering a prescribed medication and repositioning the client
D. Determining whether an expected outcome was met
Answer: C. Administering a prescribed medication and repositioning the
client
Rationale:
Implementation is the action phase where the nurse carries out planned
interventions, such as administering medications and providing direct care.
,Q3. A nurse is using Maslow's hierarchy of needs to prioritize care for
four clients. Which client need should the nurse address first?
A. A client requesting a chaplain visit
B. A client who reports feeling anxious about a procedure
C. A client with an oxygen saturation of 88%
D. A client asking about visiting hours
Answer: C. A client with an oxygen saturation of 88%
Rationale:
Physiological needs, including oxygenation, are the foundation of Maslow's
hierarchy and take priority over safety, love/belonging, esteem, or
self-actualization needs.
Q4. When using the ABC (Airway, Breathing, Circulation) framework to
prioritize care among multiple clients, which finding requires the most
immediate nursing action?
A. A client with a blood pressure of 130/84 mmHg
B. A client with stridor and increasing respiratory distress
C. A client requesting pain medication for a 4/10 pain level
D. A client due for a scheduled dressing change
Answer: B. A client with stridor and increasing respiratory distress
Rationale:
Airway takes top priority in the ABC framework; stridor with worsening distress
signals an airway compromise that must be addressed before breathing,
circulation, or comfort concerns.
, Q5. A nursing diagnosis is best described as:
A. A medical diagnosis made by the physician
B. A clinical judgment about a client's response to actual or potential health
problems that the nurse is licensed to treat
C. A laboratory test result
D. A billing code used for insurance purposes
Answer: B. A clinical judgment about a client's response to actual or
potential health problems that the nurse is licensed to treat
Rationale:
Nursing diagnoses (e.g., NANDA-I) describe human responses to health
conditions or life processes that nurses can independently address, distinct
from medical diagnoses that identify disease processes.
Q6. During the evaluation phase of the nursing process, the nurse
determines that a client's expected outcome was not met. What should
the nurse do next?
A. Discontinue the plan of care entirely
B. Reassess the client and revise the plan of care as needed
C. Document the outcome and take no further action
D. Wait until the next shift to make changes
Answer: B. Reassess the client and revise the plan of care as needed
Rationale:
The nursing process is cyclical; if an outcome is not met, the nurse should
reassess the client's status and modify the nursing diagnosis, goals, or
interventions as appropriate.
CMS Proctored Exam Study Guide
Questions & Answers with Rationales
A Comprehensive Review Covering the Nursing Process, Vital Signs, Infection
Control, Safety, Hygiene & Skin Integrity, Mobility, Nutrition & Fluids,
Elimination, Oxygenation, Medication Administration, Wound Care,
Perioperative Care, Pain Management, Communication & Legal/Ethical
Practice, and End-of-Life Care
, 1. Nursing Process & Clinical Judgment
Q1. A nurse is developing a plan of care for a newly admitted client.
Which step of the nursing process should the nurse complete first?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale:
Assessment is the first step of the nursing process; the nurse must collect
subjective and objective data before a nursing diagnosis, plan, interventions,
or evaluation can occur.
Q2. Which nursing action best reflects the 'implementation' phase of the
nursing process?
A. Collecting a health history
B. Identifying priority nursing diagnoses
C. Administering a prescribed medication and repositioning the client
D. Determining whether an expected outcome was met
Answer: C. Administering a prescribed medication and repositioning the
client
Rationale:
Implementation is the action phase where the nurse carries out planned
interventions, such as administering medications and providing direct care.
,Q3. A nurse is using Maslow's hierarchy of needs to prioritize care for
four clients. Which client need should the nurse address first?
A. A client requesting a chaplain visit
B. A client who reports feeling anxious about a procedure
C. A client with an oxygen saturation of 88%
D. A client asking about visiting hours
Answer: C. A client with an oxygen saturation of 88%
Rationale:
Physiological needs, including oxygenation, are the foundation of Maslow's
hierarchy and take priority over safety, love/belonging, esteem, or
self-actualization needs.
Q4. When using the ABC (Airway, Breathing, Circulation) framework to
prioritize care among multiple clients, which finding requires the most
immediate nursing action?
A. A client with a blood pressure of 130/84 mmHg
B. A client with stridor and increasing respiratory distress
C. A client requesting pain medication for a 4/10 pain level
D. A client due for a scheduled dressing change
Answer: B. A client with stridor and increasing respiratory distress
Rationale:
Airway takes top priority in the ABC framework; stridor with worsening distress
signals an airway compromise that must be addressed before breathing,
circulation, or comfort concerns.
, Q5. A nursing diagnosis is best described as:
A. A medical diagnosis made by the physician
B. A clinical judgment about a client's response to actual or potential health
problems that the nurse is licensed to treat
C. A laboratory test result
D. A billing code used for insurance purposes
Answer: B. A clinical judgment about a client's response to actual or
potential health problems that the nurse is licensed to treat
Rationale:
Nursing diagnoses (e.g., NANDA-I) describe human responses to health
conditions or life processes that nurses can independently address, distinct
from medical diagnoses that identify disease processes.
Q6. During the evaluation phase of the nursing process, the nurse
determines that a client's expected outcome was not met. What should
the nurse do next?
A. Discontinue the plan of care entirely
B. Reassess the client and revise the plan of care as needed
C. Document the outcome and take no further action
D. Wait until the next shift to make changes
Answer: B. Reassess the client and revise the plan of care as needed
Rationale:
The nursing process is cyclical; if an outcome is not met, the nurse should
reassess the client's status and modify the nursing diagnosis, goals, or
interventions as appropriate.
