ATI Fundamentals | NGN Final Exam Version 3 Clinical Judgment Case-
Based Questions |Answers |Rationales
1. A nurse is preparing to administer an enteral feeding to a client via a
nasogastric tube. Which of the following actions should the nurse take first?
A. Check the expiration date on the feeding formula.
B. Warm the formula to room temperature.
C. Verify the placement of the tube via pH testing or X-ray.
D. Flush the tube with 30 mL of water.
Answer: C
Rationale: The priority action before administering any feeding through a nasogastric tube
is to verify its placement to prevent aspiration into the lungs.
2. A nurse is assessing a client for orthostatic hypotension. Which of the
following findings indicates the client is experiencing this condition?
A. An increase in heart rate of 5 beats per minute.
B. A decrease in respiratory rate from 20 to 14 breaths per minute.
C. An increase in diastolic blood pressure of 5 mm Hg.
D. A decrease in systolic blood pressure of 20 mm Hg when standing.
Answer: D
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure by at
least 20 mm Hg or a decrease in diastolic blood pressure by at least 10 mm Hg within 3
minutes of standing.
,3. A nurse is teaching a client about how to use a cane. Which of the following
instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Move the stronger leg forward first when walking.
C. Hold the cane on the stronger side of the body.
D. Advance the cane 30 to 45 cm (12 to 18 in) with each step.
Answer: C
Rationale: A client should hold the cane on the stronger (unaffected) side to provide better
support and balance for the weaker leg.
4. A nurse is caring for a client who is on contact precautions. Which of the
following actions should the nurse take?
A. Wear an N95 respirator mask when entering the room.
B. Keep the client’s door closed at all times.
C. Place the client in a room with negative airflow.
D. Dedicating specific equipment, such as a stethoscope, to this client.
Answer: D
Rationale: Contact precautions require the use of dedicated equipment for the client to
prevent the spread of microorganisms to other clients.
5. A nurse is reviewing the laboratory results of a client who has a fluid volume
deficit. Which of the following findings should the nurse expect?
A. Increased urine specific gravity.
B. Decreased hematocrit level.
C. Decreased serum sodium.
D. Decreased blood urea nitrogen (BUN).
Answer: A
Rationale: In fluid volume deficit (dehydration), the urine becomes more concentrated,
resulting in an increased urine specific gravity.
, 6. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. Client reports feeling nauseated.
B. Client’s skin is warm and dry to the touch.
C. Client states, ‘I have a sharp pain in my hip.’
D. Client complains of feeling dizzy when standing.
Answer: B
Rationale: Objective data is observable and measurable information, such as skin
temperature and moisture, whereas the other options are subjective reports from the
client.
7. A nurse is planning care for a client who is at risk for pressure injuries. Which
of the following interventions should the nurse include?
A. Massage bony prominences once per shift.
B. Use a lift sheet to move the client in bed.
C. Apply cornstarch to the skin to keep it dry.
D. Reposition the client every 4 hours.
Answer: B
Rationale: Using a lift sheet prevents friction and shearing, which are major risk factors for
pressure injury development. Massaging bony prominences and using cornstarch are
contraindicated.
Based Questions |Answers |Rationales
1. A nurse is preparing to administer an enteral feeding to a client via a
nasogastric tube. Which of the following actions should the nurse take first?
A. Check the expiration date on the feeding formula.
B. Warm the formula to room temperature.
C. Verify the placement of the tube via pH testing or X-ray.
D. Flush the tube with 30 mL of water.
Answer: C
Rationale: The priority action before administering any feeding through a nasogastric tube
is to verify its placement to prevent aspiration into the lungs.
2. A nurse is assessing a client for orthostatic hypotension. Which of the
following findings indicates the client is experiencing this condition?
A. An increase in heart rate of 5 beats per minute.
B. A decrease in respiratory rate from 20 to 14 breaths per minute.
C. An increase in diastolic blood pressure of 5 mm Hg.
D. A decrease in systolic blood pressure of 20 mm Hg when standing.
Answer: D
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure by at
least 20 mm Hg or a decrease in diastolic blood pressure by at least 10 mm Hg within 3
minutes of standing.
,3. A nurse is teaching a client about how to use a cane. Which of the following
instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Move the stronger leg forward first when walking.
C. Hold the cane on the stronger side of the body.
D. Advance the cane 30 to 45 cm (12 to 18 in) with each step.
Answer: C
Rationale: A client should hold the cane on the stronger (unaffected) side to provide better
support and balance for the weaker leg.
4. A nurse is caring for a client who is on contact precautions. Which of the
following actions should the nurse take?
A. Wear an N95 respirator mask when entering the room.
B. Keep the client’s door closed at all times.
C. Place the client in a room with negative airflow.
D. Dedicating specific equipment, such as a stethoscope, to this client.
Answer: D
Rationale: Contact precautions require the use of dedicated equipment for the client to
prevent the spread of microorganisms to other clients.
5. A nurse is reviewing the laboratory results of a client who has a fluid volume
deficit. Which of the following findings should the nurse expect?
A. Increased urine specific gravity.
B. Decreased hematocrit level.
C. Decreased serum sodium.
D. Decreased blood urea nitrogen (BUN).
Answer: A
Rationale: In fluid volume deficit (dehydration), the urine becomes more concentrated,
resulting in an increased urine specific gravity.
, 6. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. Client reports feeling nauseated.
B. Client’s skin is warm and dry to the touch.
C. Client states, ‘I have a sharp pain in my hip.’
D. Client complains of feeling dizzy when standing.
Answer: B
Rationale: Objective data is observable and measurable information, such as skin
temperature and moisture, whereas the other options are subjective reports from the
client.
7. A nurse is planning care for a client who is at risk for pressure injuries. Which
of the following interventions should the nurse include?
A. Massage bony prominences once per shift.
B. Use a lift sheet to move the client in bed.
C. Apply cornstarch to the skin to keep it dry.
D. Reposition the client every 4 hours.
Answer: B
Rationale: Using a lift sheet prevents friction and shearing, which are major risk factors for
pressure injury development. Massaging bony prominences and using cornstarch are
contraindicated.
