ATI Fundamentals | NGN Exam 4 Study Guide Clinical
Judgment Practice Q&A + Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse is preparing to perform hand hygiene. Which action is the most
important to prevent the spread of microorganisms?
A. Using hot water to kill bacteria
B. Drying hands with a reusable cloth towel
C. Applying friction for at least 5 seconds
D. Rinsing hands from the wrists toward the fingertips
Answer: D
Rationale: Rinsing from the cleanest area (wrists) to the least clean area (fingertips)
ensures that contaminants are washed away rather than moved up the arms.
2. A nurse is caring for a client with a suspected diagnosis of tuberculosis. Which
type of isolation precaution should the nurse implement?
A. Contact precautions
B. Protective environment
C. Droplet precautions
D. Airborne precautions
Answer: D
Rationale: Tuberculosis requires airborne precautions, which include a private room with
negative-pressure airflow and the use of N95 respirators.
,3. A nurse is assessing a client’s fall risk. Which of the following factors should
the nurse identify as increasing the risk of falling?
A. Age of 50 years
B. Use of a walker for ambulation
C. Full range of motion in all joints
D. Oriented to person, place, and time
Answer: B
Rationale: The use of an assistive device for mobility indicates potential instability and is a
documented risk factor in fall assessment tools.
4. Which of the following actions should the nurse take when moving a client up
in bed to prevent injury to the nurse?
A. Lower the head of the bed to a flat position
B. Stand as far away from the bed as possible
C. Bend at the waist while pulling
D. Keep the knees locked while lifting
Answer: A
Rationale: Lowering the head of the bed to a flat position reduces the effect of gravity and
friction, making the move safer for the nurse’s back.
5. A nurse is caring for a client who requires a mechanical lift for transfer. What
is the priority safety action?
A. Perform the transfer alone to maintain privacy
B. Lock the wheels on the lift during the transfer
C. Lift the client as high as possible for better visibility
D. Ensure at least two staff members assist with the lift
Answer: D
Rationale: Safety protocols for mechanical lifts generally require at least two staff
members to ensure client stability and prevent falls.
, 6. A client who is post-operative is being taught how to use an incentive
spirometer. Which instruction is correct?
A. Inhale deeply and rapidly into the mouthpiece
B. Exhale forcefully into the device
C. Hold your breath for 3 to 5 seconds at the end of inhalation
D. Use the device once every 4 hours
Answer: C
Rationale: Holding the breath allows for better lung expansion and surfactant distribution,
preventing atelectasis.
7. A nurse is assessing a client for orthostatic hypotension. Which finding
indicates a positive result?
A. An increase in diastolic blood pressure of 10 mmHg when standing
B. A decrease in systolic blood pressure of 20 mmHg when standing
C. A decrease in heart rate of 15 beats/min when sitting up
D. An increase in systolic blood pressure of 5 mmHg when lying down
Answer: B
Rationale: Orthostatic hypotension is defined as a drop in systolic BP of at least 20 mmHg
or diastolic BP of at least 10 mmHg within 3 minutes of standing.
8. Which of the following describes the ‘R’ in the RACE acronym for fire safety?
A. Rescue and remove clients in immediate danger
B. Run to the nearest exit
C. Report the fire to the charge nurse
D. Relocate all equipment to the hallway
Answer: A
Rationale: RACE stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. Rescuing
clients is the immediate priority.
Judgment Practice Q&A + Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse is preparing to perform hand hygiene. Which action is the most
important to prevent the spread of microorganisms?
A. Using hot water to kill bacteria
B. Drying hands with a reusable cloth towel
C. Applying friction for at least 5 seconds
D. Rinsing hands from the wrists toward the fingertips
Answer: D
Rationale: Rinsing from the cleanest area (wrists) to the least clean area (fingertips)
ensures that contaminants are washed away rather than moved up the arms.
2. A nurse is caring for a client with a suspected diagnosis of tuberculosis. Which
type of isolation precaution should the nurse implement?
A. Contact precautions
B. Protective environment
C. Droplet precautions
D. Airborne precautions
Answer: D
Rationale: Tuberculosis requires airborne precautions, which include a private room with
negative-pressure airflow and the use of N95 respirators.
,3. A nurse is assessing a client’s fall risk. Which of the following factors should
the nurse identify as increasing the risk of falling?
A. Age of 50 years
B. Use of a walker for ambulation
C. Full range of motion in all joints
D. Oriented to person, place, and time
Answer: B
Rationale: The use of an assistive device for mobility indicates potential instability and is a
documented risk factor in fall assessment tools.
4. Which of the following actions should the nurse take when moving a client up
in bed to prevent injury to the nurse?
A. Lower the head of the bed to a flat position
B. Stand as far away from the bed as possible
C. Bend at the waist while pulling
D. Keep the knees locked while lifting
Answer: A
Rationale: Lowering the head of the bed to a flat position reduces the effect of gravity and
friction, making the move safer for the nurse’s back.
5. A nurse is caring for a client who requires a mechanical lift for transfer. What
is the priority safety action?
A. Perform the transfer alone to maintain privacy
B. Lock the wheels on the lift during the transfer
C. Lift the client as high as possible for better visibility
D. Ensure at least two staff members assist with the lift
Answer: D
Rationale: Safety protocols for mechanical lifts generally require at least two staff
members to ensure client stability and prevent falls.
, 6. A client who is post-operative is being taught how to use an incentive
spirometer. Which instruction is correct?
A. Inhale deeply and rapidly into the mouthpiece
B. Exhale forcefully into the device
C. Hold your breath for 3 to 5 seconds at the end of inhalation
D. Use the device once every 4 hours
Answer: C
Rationale: Holding the breath allows for better lung expansion and surfactant distribution,
preventing atelectasis.
7. A nurse is assessing a client for orthostatic hypotension. Which finding
indicates a positive result?
A. An increase in diastolic blood pressure of 10 mmHg when standing
B. A decrease in systolic blood pressure of 20 mmHg when standing
C. A decrease in heart rate of 15 beats/min when sitting up
D. An increase in systolic blood pressure of 5 mmHg when lying down
Answer: B
Rationale: Orthostatic hypotension is defined as a drop in systolic BP of at least 20 mmHg
or diastolic BP of at least 10 mmHg within 3 minutes of standing.
8. Which of the following describes the ‘R’ in the RACE acronym for fire safety?
A. Rescue and remove clients in immediate danger
B. Run to the nearest exit
C. Report the fire to the charge nurse
D. Relocate all equipment to the hallway
Answer: A
Rationale: RACE stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. Rescuing
clients is the immediate priority.
