ATI FUNDAMENTAL PROCTORED ACTUAL EXAM RETAKE
NEWEST VERSION 2026-2027 ACTUAL 230 +QUESTION
AND CORRECT DETAILED ANSWERS RATED A GRADE.
A nurse is admitting a client who has tuberculosis. Which of the following
types of transmission precautions should the nurse plan to initiate?
A) Droplet precautions
B) Airborne precautions
C) Protective environment
D) Contact precautions
Correct Answer: B
Rationale
Tuberculosis (TB) is caused by Mycobacterium tuberculosis, an organism
transmitted via airborne droplet nuclei that can remain suspended in the air
for extended periods. Airborne precautions are required for clients with
known or suspected TB to prevent transmission to healthcare workers and
other clients. These precautions include placing the client in a negative-
pressure airborne infection isolation room (AIIR) with at least 6 to 12 air
exchanges per hour, using an N95 respirator or high-efficiency particulate air
(HEPA) respirator when entering the room, and limiting client transport.
Option A, droplet precautions, are used for infections transmitted via large
respiratory droplets (e.g., influenza, pertussis, rubella) that do not remain
suspended in air for long periods. Option C, protective environment, is used
for immunocompromised clients to protect them from environmental
pathogens. Option D, contact precautions, are used for infections
transmitted through direct or indirect contact (e.g., MRSA, VRE, C. difficile).
,A nurse in a well-child clinic receives a telephone call from a parent who
states that their child accidentally swallowed paint thinner. The child is
awake and alert. Which of the following responses should the nurse make?
A) "Have your child drink one large glass of water."
B) "Hang up and call a poison control center hotline."
C) "Bring your child into the clinic later today."
D) "Induce vomiting in your child with syrup of ipecac."
Correct Answer: B
Rationale
When a child has ingested a potentially toxic substance, the immediate
priority is to obtain expert guidance from a poison control center. The parent
should hang up and call the poison control center hotline immediately.
Poison control centers provide immediate, evidence-based
recommendations for managing poisonings and can advise whether
emergency medical attention is needed. Option A is incorrect because
inducing vomiting or administering fluids without professional guidance can
be dangerous; for some substances, vomiting can cause further harm (e.g.,
aspiration of hydrocarbons such as paint thinner can cause chemical
pneumonitis). Option C is incorrect because delaying treatment to bring the
child to the clinic may allow the toxin to be absorbed; immediate action is
required. Option D is incorrect because syrup of ipecac is no longer
recommended for home use due to safety concerns and the risk of
aspiration.
A nurse is documenting a client's medical record. Which of the following
entries should the nurse record?
A) Oral temperature slightly elevated at 0800
B) Administered pain medication
,C) Incision without redness or drainage
D) Drank adequate amounts of fluid with meals
Correct Answer: B
Rationale
Documentation should be objective, factual, and descriptive, using
observable behaviors and specific details rather than subjective
interpretations. "Administered pain medication" is an objective, factual entry
that describes a specific nursing action. Option A, "Oral temperature slightly
elevated at 0800," is subjective because "slightly elevated" is vague and
open to interpretation; the actual temperature should be documented.
Option C, "Incision without redness or drainage," is a subjective
interpretation; the nurse should document specific observations such as
"incision edges approximated, skin color pink, no drainage noted." Option D,
"Drank adequate amounts of fluid with meals," is subjective because
"adequate" is vague; the nurse should document the actual volume of fluid
consumed.
A nurse is providing oral care for a client who is unconscious. Which of the
following actions should the nurse take?
A) Place the client in a side-lying position
B) Brush the client's teeth daily
C) Apply mineral oil to the client's lips
D) Rinse the client's mouth with an alcohol-based mouthwash
Correct Answer: A
Rationale
When providing oral care to an unconscious client, the nurse should place
the client in a side-lying position to facilitate drainage of oral secretions and
prevent aspiration. This position allows gravity to assist in keeping the airway
clear and reduces the risk of fluid entering the trachea. Option B is incorrect
, because oral care should be performed more frequently than daily; it should
be provided at least every 2 hours or as needed to maintain oral hygiene and
prevent complications such as stomatitis and dental caries. Option C is
incorrect because mineral oil should not be applied to the lips; water-soluble
lubricants or petroleum-based products are preferred. Option D is incorrect
because alcohol-based mouthwashes can dry and irritate the oral mucosa;
alcohol-free mouthwash or normal saline is preferred.
A nurse is collaborating with a risk management team about potential legal
issues involving client care. The nurse should identify which of the following
situations is an example of negligence?
A) A nurse administers a medication without first identifying the client
B) An assistive personnel discusses client care in the facility cafeteria with
visitors present
C) A nurse begins a blood transfusion without obtaining consent
D) An assistive personnel prevents a client from leaving the facility
Correct Answer: C
Rationale
Negligence is the failure to provide care that a reasonably prudent person
would provide under similar circumstances, resulting in harm to the client.
Beginning a blood transfusion without obtaining informed consent is an
example of negligence because the nurse failed to obtain the necessary legal
authorization before performing a procedure that carries significant risks.
Option A describes an act that could lead to a medication error and may
constitute negligence if harm occurs, but obtaining consent is a more direct
example of a negligent omission. Option B describes a breach of
confidentiality, which is an invasion of privacy. Option D describes false
imprisonment, which is an intentional tort.
NEWEST VERSION 2026-2027 ACTUAL 230 +QUESTION
AND CORRECT DETAILED ANSWERS RATED A GRADE.
A nurse is admitting a client who has tuberculosis. Which of the following
types of transmission precautions should the nurse plan to initiate?
A) Droplet precautions
B) Airborne precautions
C) Protective environment
D) Contact precautions
Correct Answer: B
Rationale
Tuberculosis (TB) is caused by Mycobacterium tuberculosis, an organism
transmitted via airborne droplet nuclei that can remain suspended in the air
for extended periods. Airborne precautions are required for clients with
known or suspected TB to prevent transmission to healthcare workers and
other clients. These precautions include placing the client in a negative-
pressure airborne infection isolation room (AIIR) with at least 6 to 12 air
exchanges per hour, using an N95 respirator or high-efficiency particulate air
(HEPA) respirator when entering the room, and limiting client transport.
Option A, droplet precautions, are used for infections transmitted via large
respiratory droplets (e.g., influenza, pertussis, rubella) that do not remain
suspended in air for long periods. Option C, protective environment, is used
for immunocompromised clients to protect them from environmental
pathogens. Option D, contact precautions, are used for infections
transmitted through direct or indirect contact (e.g., MRSA, VRE, C. difficile).
,A nurse in a well-child clinic receives a telephone call from a parent who
states that their child accidentally swallowed paint thinner. The child is
awake and alert. Which of the following responses should the nurse make?
A) "Have your child drink one large glass of water."
B) "Hang up and call a poison control center hotline."
C) "Bring your child into the clinic later today."
D) "Induce vomiting in your child with syrup of ipecac."
Correct Answer: B
Rationale
When a child has ingested a potentially toxic substance, the immediate
priority is to obtain expert guidance from a poison control center. The parent
should hang up and call the poison control center hotline immediately.
Poison control centers provide immediate, evidence-based
recommendations for managing poisonings and can advise whether
emergency medical attention is needed. Option A is incorrect because
inducing vomiting or administering fluids without professional guidance can
be dangerous; for some substances, vomiting can cause further harm (e.g.,
aspiration of hydrocarbons such as paint thinner can cause chemical
pneumonitis). Option C is incorrect because delaying treatment to bring the
child to the clinic may allow the toxin to be absorbed; immediate action is
required. Option D is incorrect because syrup of ipecac is no longer
recommended for home use due to safety concerns and the risk of
aspiration.
A nurse is documenting a client's medical record. Which of the following
entries should the nurse record?
A) Oral temperature slightly elevated at 0800
B) Administered pain medication
,C) Incision without redness or drainage
D) Drank adequate amounts of fluid with meals
Correct Answer: B
Rationale
Documentation should be objective, factual, and descriptive, using
observable behaviors and specific details rather than subjective
interpretations. "Administered pain medication" is an objective, factual entry
that describes a specific nursing action. Option A, "Oral temperature slightly
elevated at 0800," is subjective because "slightly elevated" is vague and
open to interpretation; the actual temperature should be documented.
Option C, "Incision without redness or drainage," is a subjective
interpretation; the nurse should document specific observations such as
"incision edges approximated, skin color pink, no drainage noted." Option D,
"Drank adequate amounts of fluid with meals," is subjective because
"adequate" is vague; the nurse should document the actual volume of fluid
consumed.
A nurse is providing oral care for a client who is unconscious. Which of the
following actions should the nurse take?
A) Place the client in a side-lying position
B) Brush the client's teeth daily
C) Apply mineral oil to the client's lips
D) Rinse the client's mouth with an alcohol-based mouthwash
Correct Answer: A
Rationale
When providing oral care to an unconscious client, the nurse should place
the client in a side-lying position to facilitate drainage of oral secretions and
prevent aspiration. This position allows gravity to assist in keeping the airway
clear and reduces the risk of fluid entering the trachea. Option B is incorrect
, because oral care should be performed more frequently than daily; it should
be provided at least every 2 hours or as needed to maintain oral hygiene and
prevent complications such as stomatitis and dental caries. Option C is
incorrect because mineral oil should not be applied to the lips; water-soluble
lubricants or petroleum-based products are preferred. Option D is incorrect
because alcohol-based mouthwashes can dry and irritate the oral mucosa;
alcohol-free mouthwash or normal saline is preferred.
A nurse is collaborating with a risk management team about potential legal
issues involving client care. The nurse should identify which of the following
situations is an example of negligence?
A) A nurse administers a medication without first identifying the client
B) An assistive personnel discusses client care in the facility cafeteria with
visitors present
C) A nurse begins a blood transfusion without obtaining consent
D) An assistive personnel prevents a client from leaving the facility
Correct Answer: C
Rationale
Negligence is the failure to provide care that a reasonably prudent person
would provide under similar circumstances, resulting in harm to the client.
Beginning a blood transfusion without obtaining informed consent is an
example of negligence because the nurse failed to obtain the necessary legal
authorization before performing a procedure that carries significant risks.
Option A describes an act that could lead to a medication error and may
constitute negligence if harm occurs, but obtaining consent is a more direct
example of a negligent omission. Option B describes a breach of
confidentiality, which is an invasion of privacy. Option D describes false
imprisonment, which is an intentional tort.
