ATI Fundamentals Proctored Exam 2020 /
2021 | ATI Fundamentals Proctored
Exam_100% Correct Answers
Question 1
A nurse is preparing to assess a client's radial pulse. Which of the following actions should the
nurse take?
A) Place the client's arm above heart level
B) Use the thumb to palpate the pulse
C) Count the pulse for 15 seconds and multiply by 4
D) Press firmly over the radial artery
Correct Answer: C) Count the pulse for 15 seconds and multiply by 4
Rationale: Counting the radial pulse for 15 seconds and multiplying by 4 is acceptable when
the pulse is regular. If the pulse is irregular, the nurse should count for a full minute. The arm
should be at heart level or supported comfortably, the thumb should never be used (it has its
own pulse), and pressure should be moderate—not firm—to avoid obliterating the pulse.
Question 2
A nurse is assessing a client's blood pressure. Which of the following factors can cause a falsely
elevated blood pressure reading? (Select All That Apply)
A) Cuff that is too small
B) Arm supported at heart level
C) Client's bladder is distended
D) Client drank coffee 15 minutes ago
E) Reinflating the cuff too slowly
Correct Answers: A, C, D, E
Rationale: A cuff that is too small, a distended bladder, recent caffeine intake, and slow cuff
deflation can all falsely elevate blood pressure. Having the arm supported at heart level is the
correct technique and does not cause a false elevation.
,Question 3
A nurse is measuring an adult client's oral temperature. Which of the following findings should
the nurse report to the provider?
A) 37.0° C (98.6° F)
B) 37.5° C (99.5° F)
C) 38.5° C (101.3° F)
D) 36.8° C (98.2° F)
Correct Answer: C) 38.5° C (101.3° F)
Rationale: An oral temperature of 38.5° C (101.3° F) is above the expected reference range
(36.5° to 37.5° C or 97.7° to 99.5° F) and indicates a fever. This finding should be reported to the
provider. The other values are within normal limits.
Question 4
A nurse is assessing a client's respirations. Which of the following actions should the nurse take?
A) Inform the client that their respirations are being counted
B) Count respirations for 15 seconds and multiply by 4
C) Place the client in a supine position
D) Observe chest rise and fall while appearing to count the pulse
Correct Answer: D) Observe chest rise and fall while appearing to count the pulse
Rationale: The nurse should observe respirations while appearing to count the radial pulse
to prevent the client from altering their breathing pattern. Respirations should be counted for a
full minute, especially if irregular. The client should be in a comfortable position, and informing
them may cause them to change their breathing pattern.
Question 5
A nurse is performing a head-to-toe assessment on a newly admitted client. Which of the
following techniques should the nurse use to assess the client's skin turgor?
A) Pinch the skin on the client's forearm
B) Press the skin over the client's sternum
,C) Gently pinch the skin on the client's abdomen or back of the hand
D) Stroke the skin on the client's thigh
Correct Answer: C) Gently pinch the skin on the client's abdomen or back of the hand
Rationale: Skin turgor is best assessed by gently pinching the skin on the abdomen, back of
the hand, or over the sternum. The skin should return to its original position immediately when
released. Poor turgor (tenting) indicates dehydration.
Question 6
A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which of
the following categories are included in this assessment? (Select All That Apply)
A) Eye opening
B) Verbal response
C) Motor response
D) Pupil reaction
E) Blood pressure
Correct Answers: A, B, C
Rationale: The Glasgow Coma Scale assesses three categories: eye opening (1-4), verbal
response (1-5), and motor response (1-6). The total score ranges from 3 to 15. Pupil reaction
and blood pressure are not part of the Glasgow Coma Scale.
Question 7
A nurse is assessing a client's pain using a numeric pain scale. The client reports pain as 8 out of
10. Which of the following actions should the nurse take first?
A) Document the pain score
B) Administer the prescribed analgesic
C) Assess the characteristics of the pain
D) Reposition the client for comfort
Correct Answer: C) Assess the characteristics of the pain
Rationale: The nurse should first assess the characteristics of the pain, including location,
duration, quality, and aggravating/relieving factors, before implementing interventions. This
, comprehensive assessment guides appropriate pain management. Documentation and
intervention follow assessment.
Question 8
A nurse is preparing to assess a client's apical pulse. At which of the following anatomical
landmarks should the nurse place the stethoscope?
A) Second intercostal space, right sternal border
B) Fifth intercostal space, left midclavicular line
C) Third intercostal space, left sternal border
D) Fourth intercostal space, right sternal border
Correct Answer: B) Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is best heard at the apex of the heart, which is located at the
fifth intercostal space at the left midclavicular line (also known as the point of maximal impulse
or PMI). This is the correct location for auscultating the apical pulse.
Question 9
A nurse is assessing an older adult client's blood pressure. The nurse obtains a reading of
158/92 mm Hg. Which of the following interpretations is correct?
A) This is a normal blood pressure reading for an older adult
B) This reading indicates stage 1 hypertension
C) This reading indicates stage 2 hypertension
D) This reading indicates a hypertensive crisis
Correct Answer: C) This reading indicates stage 2 hypertension
Rationale: According to the American Heart Association guidelines, stage 2 hypertension is
defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher. A
reading of 158/92 mm Hg meets the criteria for stage 2 hypertension.
Question 10
A nurse is performing a physical assessment on a client. Which of the following findings should
the nurse document as abnormal?
2021 | ATI Fundamentals Proctored
Exam_100% Correct Answers
Question 1
A nurse is preparing to assess a client's radial pulse. Which of the following actions should the
nurse take?
A) Place the client's arm above heart level
B) Use the thumb to palpate the pulse
C) Count the pulse for 15 seconds and multiply by 4
D) Press firmly over the radial artery
Correct Answer: C) Count the pulse for 15 seconds and multiply by 4
Rationale: Counting the radial pulse for 15 seconds and multiplying by 4 is acceptable when
the pulse is regular. If the pulse is irregular, the nurse should count for a full minute. The arm
should be at heart level or supported comfortably, the thumb should never be used (it has its
own pulse), and pressure should be moderate—not firm—to avoid obliterating the pulse.
Question 2
A nurse is assessing a client's blood pressure. Which of the following factors can cause a falsely
elevated blood pressure reading? (Select All That Apply)
A) Cuff that is too small
B) Arm supported at heart level
C) Client's bladder is distended
D) Client drank coffee 15 minutes ago
E) Reinflating the cuff too slowly
Correct Answers: A, C, D, E
Rationale: A cuff that is too small, a distended bladder, recent caffeine intake, and slow cuff
deflation can all falsely elevate blood pressure. Having the arm supported at heart level is the
correct technique and does not cause a false elevation.
,Question 3
A nurse is measuring an adult client's oral temperature. Which of the following findings should
the nurse report to the provider?
A) 37.0° C (98.6° F)
B) 37.5° C (99.5° F)
C) 38.5° C (101.3° F)
D) 36.8° C (98.2° F)
Correct Answer: C) 38.5° C (101.3° F)
Rationale: An oral temperature of 38.5° C (101.3° F) is above the expected reference range
(36.5° to 37.5° C or 97.7° to 99.5° F) and indicates a fever. This finding should be reported to the
provider. The other values are within normal limits.
Question 4
A nurse is assessing a client's respirations. Which of the following actions should the nurse take?
A) Inform the client that their respirations are being counted
B) Count respirations for 15 seconds and multiply by 4
C) Place the client in a supine position
D) Observe chest rise and fall while appearing to count the pulse
Correct Answer: D) Observe chest rise and fall while appearing to count the pulse
Rationale: The nurse should observe respirations while appearing to count the radial pulse
to prevent the client from altering their breathing pattern. Respirations should be counted for a
full minute, especially if irregular. The client should be in a comfortable position, and informing
them may cause them to change their breathing pattern.
Question 5
A nurse is performing a head-to-toe assessment on a newly admitted client. Which of the
following techniques should the nurse use to assess the client's skin turgor?
A) Pinch the skin on the client's forearm
B) Press the skin over the client's sternum
,C) Gently pinch the skin on the client's abdomen or back of the hand
D) Stroke the skin on the client's thigh
Correct Answer: C) Gently pinch the skin on the client's abdomen or back of the hand
Rationale: Skin turgor is best assessed by gently pinching the skin on the abdomen, back of
the hand, or over the sternum. The skin should return to its original position immediately when
released. Poor turgor (tenting) indicates dehydration.
Question 6
A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which of
the following categories are included in this assessment? (Select All That Apply)
A) Eye opening
B) Verbal response
C) Motor response
D) Pupil reaction
E) Blood pressure
Correct Answers: A, B, C
Rationale: The Glasgow Coma Scale assesses three categories: eye opening (1-4), verbal
response (1-5), and motor response (1-6). The total score ranges from 3 to 15. Pupil reaction
and blood pressure are not part of the Glasgow Coma Scale.
Question 7
A nurse is assessing a client's pain using a numeric pain scale. The client reports pain as 8 out of
10. Which of the following actions should the nurse take first?
A) Document the pain score
B) Administer the prescribed analgesic
C) Assess the characteristics of the pain
D) Reposition the client for comfort
Correct Answer: C) Assess the characteristics of the pain
Rationale: The nurse should first assess the characteristics of the pain, including location,
duration, quality, and aggravating/relieving factors, before implementing interventions. This
, comprehensive assessment guides appropriate pain management. Documentation and
intervention follow assessment.
Question 8
A nurse is preparing to assess a client's apical pulse. At which of the following anatomical
landmarks should the nurse place the stethoscope?
A) Second intercostal space, right sternal border
B) Fifth intercostal space, left midclavicular line
C) Third intercostal space, left sternal border
D) Fourth intercostal space, right sternal border
Correct Answer: B) Fifth intercostal space, left midclavicular line
Rationale: The apical pulse is best heard at the apex of the heart, which is located at the
fifth intercostal space at the left midclavicular line (also known as the point of maximal impulse
or PMI). This is the correct location for auscultating the apical pulse.
Question 9
A nurse is assessing an older adult client's blood pressure. The nurse obtains a reading of
158/92 mm Hg. Which of the following interpretations is correct?
A) This is a normal blood pressure reading for an older adult
B) This reading indicates stage 1 hypertension
C) This reading indicates stage 2 hypertension
D) This reading indicates a hypertensive crisis
Correct Answer: C) This reading indicates stage 2 hypertension
Rationale: According to the American Heart Association guidelines, stage 2 hypertension is
defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher. A
reading of 158/92 mm Hg meets the criteria for stage 2 hypertension.
Question 10
A nurse is performing a physical assessment on a client. Which of the following findings should
the nurse document as abnormal?
