Actual ATI RN Fundamentals 2026 Proctored Exam
with NGN 70 Questions and Answers Top Score Level
3 RN ATI Fundamentals Nursing 2026 Assessment Per
ATI Marking Scheme
1. A nurse is assessing a client who reports a "racing heart." Which action should the nurse take
first?
A. Obtain a 12-lead ECG
B. Measure the client's apical pulse for one full minute
C. Administer prescribed PRN metoprolol
D. Ask the client to bear down and cough
Correct: B
Measuring the apical pulse for a full minute is the first nursing action to obtain accurate
data about the reported symptom. Administering medication or obtaining an ECG requires a
prescription or further assessment. Having the client bear down (Valsalva) is inappropriate
without knowing the rhythm and could worsen the situation.
2. A nurse is preparing to measure a client's blood pressure. Which action is correct?
A. Place the cuff 2.5 cm (1 in) above the antecubital fossa
B. Inflate the cuff to 200 mm Hg regardless of baseline
C. Have the client sit with the arm below heart level
D. Use a cuff whose bladder width is 40% of arm circumference
Correct: A
The cuff should be placed 2.5 cm (1 in) above the antecubital fossa. Cuff bladder width
should be about 40% and length about 80% of arm circumference. The arm should be at heart
level. Inflating to a fixed 200 mm Hg is not recommended; inflate 20–30 mm Hg above the point
at which the pulse disappears.
3. A nurse notes a client's oral temperature is 38.9°C (102°F). Which additional assessment is
the priority?
A. Review the medication administration record for antipyretics
B. Assess for signs of dehydration and obtain a full set of vital signs
,C. Apply a cooling blanket
D. Notify the provider immediately
Correct: B
The priority is to complete the assessment—obtain full vital signs and assess for
dehydration—before intervening. Antipyretics require an order (unless a protocol exists),
cooling blankets can cause shivering, and the provider should be notified after the nurse has
gathered complete data.
4. A nurse is assessing a client's radial pulse and notes it is irregular. Which action should the
nurse take next?
A. Document the irregular rate as found
B. Reassess the pulse apically for one full minute
C. Ask another nurse to verify the finding
D. Obtain an order for a cardiac monitor
Correct: B
When a peripheral pulse is irregular, the nurse should assess the apical pulse for a full
minute to obtain an accurate rate and rhythm. Documentation should reflect accurate data;
verification by another nurse is not the immediate next step, and a monitor requires an order.
5. SATA: A nurse is assessing an older adult client for risk of falls. Which findings increase the
client's risk? (Select all that apply.)
A. Taking a diuretic
B. History of cataracts
C. Use of a cane
D. Peripheral neuropathy
E. Recent hospitalization
F. Blood pressure 118/76 mm Hg
Correct: A, B, D, E
Diuretics can cause orthostatic hypotension and urinary urgency. Cataracts impair vision.
Peripheral neuropathy reduces sensation and proprioception. Recent hospitalization is
associated with deconditioning and increased fall risk. A cane is an assistive device that reduces
risk, and a BP of 118/76 is within normal limits.
,6. A nurse is assessing a client's pain using the PQRST method. Which question reflects the "R"
component?
A. "What makes the pain worse or better?"
B. "Where is the pain located?"
C. "How would you describe the pain?"
D. "When did the pain start?"
Correct: A
PQRST: P = Provocative/Palliative (what makes it worse/better), Q = Quality, R =
Region/Radiation, S = Severity, T = Timing. "What makes the pain worse or better?" is the
provocative/palliative component.
7. A nurse is performing a focused respiratory assessment. Which finding requires immediate
follow-up?
A. Respiratory rate 18/min
B. Oxygen saturation 94% on room air
C. Use of accessory muscles with nasal flaring
D. Bilateral crackles that clear with coughing
Correct: C
Accessory muscle use and nasal flaring indicate increased work of breathing and impending
respiratory distress. A rate of 18, SpO₂ of 94%, and crackles that clear with coughing are not
immediately life-threatening.
8. A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which
score indicates the need for immediate intervention?
A. 15
B. 13
C. 10
D. 8
Correct: D
A GCS of 8 or less indicates severe neurological impairment and generally requires airway
protection. Scores of 13–15 indicate mild impairment; 9–12 moderate; ≤8 severe.
, 9. A nurse is assessing a client for orthostatic hypotension. Which instruction should the nurse
give?
A. "Remain lying down while I measure your blood pressure."
B. "Sit up and I will measure your blood pressure immediately."
C. "Stand up quickly so I can get an accurate reading."
D. "Lie down, sit up, then stand, with a blood pressure check at each position."
Correct: D
Orthostatic vital signs are measured with the client lying, sitting, and standing, with BP and
pulse obtained in each position. A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3
minutes of standing indicates orthostatic hypotension.
10. A nurse is assessing a client's skin turgor. Which finding is most consistent with dehydration?
A. Skin tents when pinched
B. Skin returns to normal immediately
C. Moist mucous membranes
D. Bilateral pedal edema
Correct: A
Tent skin turgor that remains elevated after pinching indicates dehydration. Immediate
return indicates adequate hydration. Moist mucous membranes are normal. Pedal edema
suggests fluid overload.
11. A nurse is assessing a client with a suspected head injury. Which finding is the earliest
indicator of increased intracranial pressure?
A. Decreased level of consciousness
B. Fixed dilated pupils
C. Cushing's triad
D. Decerebrate posturing
Correct: A
A change in level of consciousness is the earliest and most sensitive indicator of increased
ICP. Pupillary changes, Cushing's triad (bradycardia, hypertension, irregular respirations), and
posturing occur later.
with NGN 70 Questions and Answers Top Score Level
3 RN ATI Fundamentals Nursing 2026 Assessment Per
ATI Marking Scheme
1. A nurse is assessing a client who reports a "racing heart." Which action should the nurse take
first?
A. Obtain a 12-lead ECG
B. Measure the client's apical pulse for one full minute
C. Administer prescribed PRN metoprolol
D. Ask the client to bear down and cough
Correct: B
Measuring the apical pulse for a full minute is the first nursing action to obtain accurate
data about the reported symptom. Administering medication or obtaining an ECG requires a
prescription or further assessment. Having the client bear down (Valsalva) is inappropriate
without knowing the rhythm and could worsen the situation.
2. A nurse is preparing to measure a client's blood pressure. Which action is correct?
A. Place the cuff 2.5 cm (1 in) above the antecubital fossa
B. Inflate the cuff to 200 mm Hg regardless of baseline
C. Have the client sit with the arm below heart level
D. Use a cuff whose bladder width is 40% of arm circumference
Correct: A
The cuff should be placed 2.5 cm (1 in) above the antecubital fossa. Cuff bladder width
should be about 40% and length about 80% of arm circumference. The arm should be at heart
level. Inflating to a fixed 200 mm Hg is not recommended; inflate 20–30 mm Hg above the point
at which the pulse disappears.
3. A nurse notes a client's oral temperature is 38.9°C (102°F). Which additional assessment is
the priority?
A. Review the medication administration record for antipyretics
B. Assess for signs of dehydration and obtain a full set of vital signs
,C. Apply a cooling blanket
D. Notify the provider immediately
Correct: B
The priority is to complete the assessment—obtain full vital signs and assess for
dehydration—before intervening. Antipyretics require an order (unless a protocol exists),
cooling blankets can cause shivering, and the provider should be notified after the nurse has
gathered complete data.
4. A nurse is assessing a client's radial pulse and notes it is irregular. Which action should the
nurse take next?
A. Document the irregular rate as found
B. Reassess the pulse apically for one full minute
C. Ask another nurse to verify the finding
D. Obtain an order for a cardiac monitor
Correct: B
When a peripheral pulse is irregular, the nurse should assess the apical pulse for a full
minute to obtain an accurate rate and rhythm. Documentation should reflect accurate data;
verification by another nurse is not the immediate next step, and a monitor requires an order.
5. SATA: A nurse is assessing an older adult client for risk of falls. Which findings increase the
client's risk? (Select all that apply.)
A. Taking a diuretic
B. History of cataracts
C. Use of a cane
D. Peripheral neuropathy
E. Recent hospitalization
F. Blood pressure 118/76 mm Hg
Correct: A, B, D, E
Diuretics can cause orthostatic hypotension and urinary urgency. Cataracts impair vision.
Peripheral neuropathy reduces sensation and proprioception. Recent hospitalization is
associated with deconditioning and increased fall risk. A cane is an assistive device that reduces
risk, and a BP of 118/76 is within normal limits.
,6. A nurse is assessing a client's pain using the PQRST method. Which question reflects the "R"
component?
A. "What makes the pain worse or better?"
B. "Where is the pain located?"
C. "How would you describe the pain?"
D. "When did the pain start?"
Correct: A
PQRST: P = Provocative/Palliative (what makes it worse/better), Q = Quality, R =
Region/Radiation, S = Severity, T = Timing. "What makes the pain worse or better?" is the
provocative/palliative component.
7. A nurse is performing a focused respiratory assessment. Which finding requires immediate
follow-up?
A. Respiratory rate 18/min
B. Oxygen saturation 94% on room air
C. Use of accessory muscles with nasal flaring
D. Bilateral crackles that clear with coughing
Correct: C
Accessory muscle use and nasal flaring indicate increased work of breathing and impending
respiratory distress. A rate of 18, SpO₂ of 94%, and crackles that clear with coughing are not
immediately life-threatening.
8. A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which
score indicates the need for immediate intervention?
A. 15
B. 13
C. 10
D. 8
Correct: D
A GCS of 8 or less indicates severe neurological impairment and generally requires airway
protection. Scores of 13–15 indicate mild impairment; 9–12 moderate; ≤8 severe.
, 9. A nurse is assessing a client for orthostatic hypotension. Which instruction should the nurse
give?
A. "Remain lying down while I measure your blood pressure."
B. "Sit up and I will measure your blood pressure immediately."
C. "Stand up quickly so I can get an accurate reading."
D. "Lie down, sit up, then stand, with a blood pressure check at each position."
Correct: D
Orthostatic vital signs are measured with the client lying, sitting, and standing, with BP and
pulse obtained in each position. A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3
minutes of standing indicates orthostatic hypotension.
10. A nurse is assessing a client's skin turgor. Which finding is most consistent with dehydration?
A. Skin tents when pinched
B. Skin returns to normal immediately
C. Moist mucous membranes
D. Bilateral pedal edema
Correct: A
Tent skin turgor that remains elevated after pinching indicates dehydration. Immediate
return indicates adequate hydration. Moist mucous membranes are normal. Pedal edema
suggests fluid overload.
11. A nurse is assessing a client with a suspected head injury. Which finding is the earliest
indicator of increased intracranial pressure?
A. Decreased level of consciousness
B. Fixed dilated pupils
C. Cushing's triad
D. Decerebrate posturing
Correct: A
A change in level of consciousness is the earliest and most sensitive indicator of increased
ICP. Pupillary changes, Cushing's triad (bradycardia, hypertension, irregular respirations), and
posturing occur later.
