ATI Fundamentals CMS Proctored Exam – 70 Verified
Questions with Detailed Rationales
1. A nurse is preparing to assess a client's blood pressure. Which action
should the nurse take first?
A. Place the cuff over the client's clothing
B. Position the client's arm at heart level
C. Ask the client to stand
D. Select a cuff that is smaller than the client's arm
Answer: B
Rationale: The arm should be supported at heart level to obtain an
accurate blood pressure measurement. The cuff should be applied to
bare skin and appropriately sized.
2. A nurse is caring for a client who has a prescription for oxygen at 2
L/min via nasal cannula. Which finding requires immediate
intervention?
A. Oxygen saturation of 96%
B. Dry nasal mucosa
C. Smoking while receiving oxygen
D. Respiratory rate of 18/min
Answer: C
Rationale: Oxygen supports combustion. Smoking or an open flame
near supplemental oxygen creates a serious fire hazard.
3. Which intervention is most effective for preventing the spread of
infection?
,A. Wearing a mask for every client encounter
B. Performing hand hygiene
C. Administering prophylactic antibiotics
D. Wearing sterile gloves during routine care
Answer: B
Rationale: Hand hygiene is the primary measure for reducing
transmission of microorganisms between clients, healthcare personnel,
and the environment.
4. A nurse is preparing to administer an oral medication. Which action
is appropriate?
A. Leave the medication at the bedside
B. Verify the medication against the prescription
C. Crush all tablets before administration
D. Ask another client to identify the medication
Answer: B
Rationale: Medication administration requires verification of the
medication, dose, route, time, and client according to the applicable
medication-safety checks.
5. A client reports dizziness when getting out of bed. Which action
should the nurse take?
A. Encourage the client to stand quickly
B. Assist the client to sit at the bedside before standing
C. Tell the client to walk independently
D. Restrict all oral fluids
, Answer: B
Rationale: Sitting at the bedside allows the client to adjust to positional
changes and helps reduce the risk of orthostatic hypotension and falls.
6. A nurse is caring for a client on fall precautions. Which intervention is
appropriate?
A. Keep all four side rails raised
B. Keep the bed in the lowest position
C. Place the call light outside the client's reach
D. Encourage the client to walk without assistance
Answer: B
Rationale: A low bed decreases injury risk if a client attempts to get out
of bed. The call light should remain within reach.
7. A nurse is assessing a client's pain. Which question is most
appropriate?
A. "You aren't having much pain, are you?"
B. "Why do you think you're in pain?"
C. "What does your pain feel like?"
D. "Is your pain caused by anxiety?"
Answer: C
Rationale: Open-ended, nonleading questions encourage the client to
describe pain characteristics accurately.
8. A client has a pressure injury over the sacral area. Which intervention
is appropriate?
A. Massage the injured area
Questions with Detailed Rationales
1. A nurse is preparing to assess a client's blood pressure. Which action
should the nurse take first?
A. Place the cuff over the client's clothing
B. Position the client's arm at heart level
C. Ask the client to stand
D. Select a cuff that is smaller than the client's arm
Answer: B
Rationale: The arm should be supported at heart level to obtain an
accurate blood pressure measurement. The cuff should be applied to
bare skin and appropriately sized.
2. A nurse is caring for a client who has a prescription for oxygen at 2
L/min via nasal cannula. Which finding requires immediate
intervention?
A. Oxygen saturation of 96%
B. Dry nasal mucosa
C. Smoking while receiving oxygen
D. Respiratory rate of 18/min
Answer: C
Rationale: Oxygen supports combustion. Smoking or an open flame
near supplemental oxygen creates a serious fire hazard.
3. Which intervention is most effective for preventing the spread of
infection?
,A. Wearing a mask for every client encounter
B. Performing hand hygiene
C. Administering prophylactic antibiotics
D. Wearing sterile gloves during routine care
Answer: B
Rationale: Hand hygiene is the primary measure for reducing
transmission of microorganisms between clients, healthcare personnel,
and the environment.
4. A nurse is preparing to administer an oral medication. Which action
is appropriate?
A. Leave the medication at the bedside
B. Verify the medication against the prescription
C. Crush all tablets before administration
D. Ask another client to identify the medication
Answer: B
Rationale: Medication administration requires verification of the
medication, dose, route, time, and client according to the applicable
medication-safety checks.
5. A client reports dizziness when getting out of bed. Which action
should the nurse take?
A. Encourage the client to stand quickly
B. Assist the client to sit at the bedside before standing
C. Tell the client to walk independently
D. Restrict all oral fluids
, Answer: B
Rationale: Sitting at the bedside allows the client to adjust to positional
changes and helps reduce the risk of orthostatic hypotension and falls.
6. A nurse is caring for a client on fall precautions. Which intervention is
appropriate?
A. Keep all four side rails raised
B. Keep the bed in the lowest position
C. Place the call light outside the client's reach
D. Encourage the client to walk without assistance
Answer: B
Rationale: A low bed decreases injury risk if a client attempts to get out
of bed. The call light should remain within reach.
7. A nurse is assessing a client's pain. Which question is most
appropriate?
A. "You aren't having much pain, are you?"
B. "Why do you think you're in pain?"
C. "What does your pain feel like?"
D. "Is your pain caused by anxiety?"
Answer: C
Rationale: Open-ended, nonleading questions encourage the client to
describe pain characteristics accurately.
8. A client has a pressure injury over the sacral area. Which intervention
is appropriate?
A. Massage the injured area
