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Exam (elaborations)

All ATI RN 2026 Ultimate Bundle Featuring All Actual and Retake Assessments

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All ATI RN 2026 Ultimate Bundle Featuring All Actual and Retake Assessments

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All ATI RN 2026 Ultimate Bundle
Featuring All Actual and Retake
Assessments
Section 1: Fundamentals of Nursing (Questions 1–15)



Question 1
A nurse is preparing to administer a medication via a nasogastric (NG) tube. Which action
should the nurse take first?

A. Flush the tube with 30 mL of water
B. Verify tube placement by aspirating gastric contents and checking pH
C. Crush the medication and mix with 10 mL of water
D. Position the client in a supine position

Correct Answer: B

Rationale: Verifying NG tube placement is the priority before administering any medication.
The nurse should aspirate gastric contents and check the pH (gastric pH is typically 0–4).
Auscultating air bolus is no longer considered reliable. Option A is incorrect because flushing
should occur after verification. Option C is incorrect because medication preparation occurs
after verification. Option D is incorrect because the client should be positioned upright (at least
30–45 degrees) to prevent aspiration.



Question 2
A nurse is assessing a client who has been immobile for 3 days. Which finding indicates the
client is at highest risk for developing a pressure injury?

A. Braden Scale score of 16
B. Serum albumin level of 3.8 g/dL
C. Moist skin with occasional diaphoresis
D. Body mass index (BMI) of 24

Correct Answer: A

, Rationale: A Braden Scale score of 16 indicates mild risk for pressure injury development
(scores range from 6–23, with lower scores indicating higher risk). However, among the options
provided, this is the most significant risk factor. Option B indicates normal nutritional status.
Option C indicates mildly increased moisture, which is a risk factor but less significant than
impaired mobility. Option D indicates normal BMI, which is not a risk factor.



Question 3 (SATA)
A nurse is teaching a client about proper hand hygiene. Which statements by the client indicate
understanding? Select all that apply.

A. "I should wash my hands for at least 20 seconds with soap and water."
B. "Alcohol-based hand rubs are effective against C. difficile spores."
C. "I should rub my hands together until they are dry when using alcohol-based hand rub."
D. "I need to wash my hands before and after eating."
E. "Artificial nails are acceptable as long as they are kept short."

Correct Answers: A, C, D

Rationale: Option A is correct—20 seconds is the recommended duration for handwashing.
Option C is correct—hands should be rubbed until dry to ensure effective antimicrobial action.
Option D is correct—hand hygiene should be performed before and after eating. Option B is
incorrect because alcohol-based hand rubs are NOT effective against C. difficile spores; soap and
water must be used. Option E is incorrect because artificial nails harbor microorganisms and are
prohibited for healthcare workers.



Question 4
A nurse is caring for a client who requires a sterile dressing change. Which action demonstrates
proper sterile technique?

A. Reaching over the sterile field to obtain supplies
B. Placing sterile supplies 2 inches from the edge of the sterile field
C. Using a sterile glove to touch only sterile items
D. Allowing the sterile field to remain open while gathering additional supplies

Correct Answer: C

Rationale: Only sterile items may touch other sterile items. Option A is incorrect because
reaching over a sterile field contaminates it. Option B is incorrect because sterile supplies
should be placed at least 1 inch from the edge, but items falling below the table level are

,considered contaminated. Option D is incorrect because the sterile field must be continuously
monitored and cannot be left unattended.



Question 5
A nurse is documenting in a client's medical record. Which notation is most appropriate?

A. "Client is being difficult and refuses to take medications."
B. "Client states, 'I don't want to take that pill anymore.'"
C. "Client is noncompliant with medication regimen."
D. "Client is a drug-seeking behavior patient."

Correct Answer: B

Rationale: Documentation should be objective, factual, and include direct client quotes
when possible. Option A is subjective and judgmental. Option C is a conclusion without
supporting data. Option D is a stigmatizing label and not objective documentation.



Question 6
A nurse is preparing to insert an indwelling urinary catheter. Which action is correct?

A. Use clean gloves for the procedure
B. Cleanse the meatus from back to front in females
C. Inflate the balloon before confirming urine return
D. Advance the catheter until urine returns, then advance 1–2 inches further

Correct Answer: D

Rationale: After urine return, the catheter should be advanced an additional 1–2 inches to
ensure the balloon is in the bladder and not the urethra. Option A is incorrect—sterile gloves
are required. Option B is incorrect—cleansing should be front to back to prevent introducing
bacteria from the rectum. Option C is incorrect—the balloon should only be inflated after
confirming urine return.



Question 7 (SATA)
A nurse is assessing a client for signs of dehydration. Which findings should the nurse expect?
Select all that apply.

, A. Tachycardia
B. Hypertension
C. Dry mucous membranes
D. Decreased skin turgor
E. Weight gain

Correct Answers: A, C, D

Rationale: Option A is correct—tachycardia occurs as the heart compensates for decreased
blood volume. Option C is correct—dry mucous membranes are a classic sign of dehydration.
Option D is correct—decreased skin turgor indicates poor hydration. Option B is incorrect—
hypotension, not hypertension, is associated with dehydration. Option E is incorrect—weight
loss, not gain, occurs with dehydration.



Question 8
A nurse is caring for a client who has a new prescription for fall precautions. Which intervention
should the nurse implement first?

A. Place the call light within reach
B. Apply a fall risk bracelet
C. Orient the client to the environment
D. Keep the bed in the lowest position

Correct Answer: C

Rationale: Orienting the client to the environment is the priority action to prevent falls, as it
addresses the client's awareness and safety. Options A, B, and D are all important fall prevention
interventions but should follow orientation.



Question 9
A nurse is performing a focused respiratory assessment. Which technique should the nurse use
to assess for tactile fremitus?

A. Place hands on the chest wall and ask the client to speak
B. Percuss the chest wall while the client holds their breath
C. Auscultate breath sounds while the client coughs
D. Inspect the chest for symmetric expansion

Correct Answer: A

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