ATI FUNDAMENTALS PROCTORED
EXAM (9 LATEST VERSIONS): (A
BEST DOCUMENTS FOR EXAM)
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I don't want to
have this surgery. I'm scared." Which of the following actions should the nurse take first?
A. Notify the surgeon that the client is refusing the procedure.
B. Explain the risks and benefits of the procedure to the client.
C. Ask the client to describe their fears.
D. Administer the prescribed preoperative anxiolytic.
Correct Answer: C
Rationale: The first step in the nursing process is assessment. By asking the client to
describe their fears, the nurse is gathering subjective data. This is the priority action before
notifying the surgeon or providing education. Explaining risks and benefits is the provider's
responsibility, and administering medication is premature until the nurse understands the
client's concerns.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate?
A. Administering oral medications to a stable client.
B. Assessing a client's incision for signs of infection.
C. Ambulating a client who is 1-day postoperative.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C
Rationale: Ambulating a stable client is a routine task that can be safely delegated to an AP.
Administering medications, assessing clients, and providing teaching are all tasks that require
the skills and judgment of a licensed nurse and cannot be delegated to an AP.
3. A nurse is using the SBAR communication tool to report a client's status to a provider.
Which of the following information should the nurse include in the "A" section of SBAR?
A. "The client is a 68-year-old male who had a total knee arthroplasty this morning."
B. "I think the client is experiencing a pulmonary embolism."
C. "The client's heart rate is 120/min and their oxygen saturation is 88% on room air."
D. "I am calling because I need an order for a stat chest CT."
,Correct Answer: C
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
"A" (Assessment) section includes the nurse's clinical findings, such as vital signs and physical
assessment data. The client's demographic and surgical history is "Background." The nurse's
conclusion about a potential PE is an assessment, but the objective data (HR, O2 sat) is the core
of the "A" component. The request for an order is the "Recommendation."
4. A nurse is reviewing a client's medical record and notes a prescription for "Morphine
sulfate 2 mg IV every 2 hours PRN for severe pain." Which of the following is a complete and
accurate nursing intervention?
A. Administer the medication as prescribed.
B. Assess the client's pain level, then administer the medication if the pain is severe.
C. Ask another nurse to verify the order before administration.
D. Hold the medication and call the provider to clarify the order.
Correct Answer: B
Rationale: The nursing process requires assessment before intervention. The nurse must
first assess the client's pain level to determine if it meets the "severe" criteria specified in the
PRN order. Administering the medication without assessing the pain is unsafe. The order itself is
complete, so clarification or verification is not the priority action.
5. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. Which of the
following actions should the nurse take during the evaluation phase of the nursing process?
A. Develop a plan for the client to learn how to self-administer insulin.
B. Determine if the client's blood glucose levels have stabilized.
C. Teach the client about the signs and symptoms of hypoglycemia.
D. Identify the client's readiness to learn about diabetes management.
Correct Answer: B
Rationale: The evaluation phase of the nursing process involves determining the
effectiveness of the interventions and whether the client's goals have been met. Measuring
whether blood glucose levels have stabilized is a direct evaluation of the effectiveness of the
treatment plan. Developing a plan is part of the planning phase, teaching is an intervention, and
identifying readiness to learn is an assessment.
6. A nurse is preparing to perform a client's admission assessment. Which of the following
actions should the nurse take to establish a therapeutic relationship?
A. Use medical jargon to explain procedures.
B. Sit at the client's bedside and maintain eye contact.
,C. Complete the assessment quickly to allow the client to rest.
D. Ask only closed-ended questions to obtain information.
Correct Answer: B
Rationale: Sitting at the client's bedside and maintaining eye contact are nonverbal
communication techniques that convey respect, presence, and a willingness to listen, which
helps establish a therapeutic relationship. Using medical jargon is a barrier to communication.
Rushing the assessment and using only closed-ended questions hinders the development of
trust and a comprehensive understanding of the client.
7. A nurse is a member of an interprofessional team caring for a client. Which of the following
actions demonstrates collaboration with the team?
A. The nurse develops the care plan independently.
B. The nurse consults with the physical therapist about the client's mobility goals.
C. The nurse asks the AP to perform a wound dressing change.
D. The nurse tells the provider which medication to prescribe.
Correct Answer: B
Rationale: Collaboration involves working jointly with other members of the healthcare
team who have different areas of expertise. Consulting with a physical therapist about mobility
goals is a prime example of interprofessional collaboration. The other options represent
unilateral decision-making or inappropriate delegation.
8. A nurse is caring for an older adult client who has advanced directives. The client is found
unresponsive and pulseless. Which of the following actions should the nurse take?
A. Begin CPR immediately.
B. Check the client's advance directive to see if they have a DNR order.
C. Call a code blue and wait for the code team.
D. Administer a dose of epinephrine.
Correct Answer: B
Rationale: When a client is found unresponsive, the nurse's first action is to assess for a
DNR (Do Not Resuscitate) or AND (Allow Natural Death) order in the client's chart. If a valid DNR
order is present, CPR should not be initiated. If no such order exists, the nurse should begin CPR
immediately.
9. A nurse is reviewing the plan of care for a client who is at risk for falls. Which of the
following interventions should the nurse implement? (SATA)
A. Place the client in a room near the nurses' station.
B. Keep the bed in the lowest position.
, C. Encourage the use of a walker for ambulation.
D. Apply a vest restraint to keep the client in bed.
E. Instruct the client to use the call light for assistance.
Correct Answer: A, B, C, E
Rationale: Placing the client near the nurses' station allows for frequent observation.
Keeping the bed low reduces the risk of injury if a fall occurs. Encouraging the use of a walker
promotes safe mobility. Instructing the client to call for assistance is a crucial safety measure.
Restraints are a last resort and are not a routine intervention for fall prevention; they can
increase the risk of injury.
10. A nurse is prioritizing care for four clients. Which of the following clients should the nurse
assess first?
A. A client who is 2 days postoperative and requests pain medication.
B. A client who has a new onset of confusion and slurred speech.
C. A client who needs to be taught how to check their blood glucose.
D. A client who is scheduled for discharge in 1 hour.
Correct Answer: B
Rationale: The nurse should first assess the client with a new onset of confusion and slurred
speech. These are signs of a potential neurological emergency, such as a stroke. This client is the
most unstable and has the highest priority. The other clients have needs that are important but
not immediately life-threatening.
11. A nurse is preparing to transfer a client from the bed to a chair. Which of the following
actions should the nurse take to prevent injury to themselves?
A. Keep their feet close together.
B. Bend at the waist.
C. Use a mechanical lift if the client is unable to bear weight.
D. Twist their torso while lifting.
Correct Answer: C
Rationale: The nurse should use a mechanical lift for any client who cannot bear weight, as
this is the safest method for both the client and the nurse. Keeping feet close together and
bending at the waist are improper body mechanics. Twisting the torso while lifting greatly
increases the risk of back injury.
12. An AP reports to the nurse that a client's blood pressure is 88/50 mm Hg. Which of the
following actions should the nurse take first?
A. Ask the AP to recheck the blood pressure.
EXAM (9 LATEST VERSIONS): (A
BEST DOCUMENTS FOR EXAM)
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I don't want to
have this surgery. I'm scared." Which of the following actions should the nurse take first?
A. Notify the surgeon that the client is refusing the procedure.
B. Explain the risks and benefits of the procedure to the client.
C. Ask the client to describe their fears.
D. Administer the prescribed preoperative anxiolytic.
Correct Answer: C
Rationale: The first step in the nursing process is assessment. By asking the client to
describe their fears, the nurse is gathering subjective data. This is the priority action before
notifying the surgeon or providing education. Explaining risks and benefits is the provider's
responsibility, and administering medication is premature until the nurse understands the
client's concerns.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate?
A. Administering oral medications to a stable client.
B. Assessing a client's incision for signs of infection.
C. Ambulating a client who is 1-day postoperative.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C
Rationale: Ambulating a stable client is a routine task that can be safely delegated to an AP.
Administering medications, assessing clients, and providing teaching are all tasks that require
the skills and judgment of a licensed nurse and cannot be delegated to an AP.
3. A nurse is using the SBAR communication tool to report a client's status to a provider.
Which of the following information should the nurse include in the "A" section of SBAR?
A. "The client is a 68-year-old male who had a total knee arthroplasty this morning."
B. "I think the client is experiencing a pulmonary embolism."
C. "The client's heart rate is 120/min and their oxygen saturation is 88% on room air."
D. "I am calling because I need an order for a stat chest CT."
,Correct Answer: C
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
"A" (Assessment) section includes the nurse's clinical findings, such as vital signs and physical
assessment data. The client's demographic and surgical history is "Background." The nurse's
conclusion about a potential PE is an assessment, but the objective data (HR, O2 sat) is the core
of the "A" component. The request for an order is the "Recommendation."
4. A nurse is reviewing a client's medical record and notes a prescription for "Morphine
sulfate 2 mg IV every 2 hours PRN for severe pain." Which of the following is a complete and
accurate nursing intervention?
A. Administer the medication as prescribed.
B. Assess the client's pain level, then administer the medication if the pain is severe.
C. Ask another nurse to verify the order before administration.
D. Hold the medication and call the provider to clarify the order.
Correct Answer: B
Rationale: The nursing process requires assessment before intervention. The nurse must
first assess the client's pain level to determine if it meets the "severe" criteria specified in the
PRN order. Administering the medication without assessing the pain is unsafe. The order itself is
complete, so clarification or verification is not the priority action.
5. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. Which of the
following actions should the nurse take during the evaluation phase of the nursing process?
A. Develop a plan for the client to learn how to self-administer insulin.
B. Determine if the client's blood glucose levels have stabilized.
C. Teach the client about the signs and symptoms of hypoglycemia.
D. Identify the client's readiness to learn about diabetes management.
Correct Answer: B
Rationale: The evaluation phase of the nursing process involves determining the
effectiveness of the interventions and whether the client's goals have been met. Measuring
whether blood glucose levels have stabilized is a direct evaluation of the effectiveness of the
treatment plan. Developing a plan is part of the planning phase, teaching is an intervention, and
identifying readiness to learn is an assessment.
6. A nurse is preparing to perform a client's admission assessment. Which of the following
actions should the nurse take to establish a therapeutic relationship?
A. Use medical jargon to explain procedures.
B. Sit at the client's bedside and maintain eye contact.
,C. Complete the assessment quickly to allow the client to rest.
D. Ask only closed-ended questions to obtain information.
Correct Answer: B
Rationale: Sitting at the client's bedside and maintaining eye contact are nonverbal
communication techniques that convey respect, presence, and a willingness to listen, which
helps establish a therapeutic relationship. Using medical jargon is a barrier to communication.
Rushing the assessment and using only closed-ended questions hinders the development of
trust and a comprehensive understanding of the client.
7. A nurse is a member of an interprofessional team caring for a client. Which of the following
actions demonstrates collaboration with the team?
A. The nurse develops the care plan independently.
B. The nurse consults with the physical therapist about the client's mobility goals.
C. The nurse asks the AP to perform a wound dressing change.
D. The nurse tells the provider which medication to prescribe.
Correct Answer: B
Rationale: Collaboration involves working jointly with other members of the healthcare
team who have different areas of expertise. Consulting with a physical therapist about mobility
goals is a prime example of interprofessional collaboration. The other options represent
unilateral decision-making or inappropriate delegation.
8. A nurse is caring for an older adult client who has advanced directives. The client is found
unresponsive and pulseless. Which of the following actions should the nurse take?
A. Begin CPR immediately.
B. Check the client's advance directive to see if they have a DNR order.
C. Call a code blue and wait for the code team.
D. Administer a dose of epinephrine.
Correct Answer: B
Rationale: When a client is found unresponsive, the nurse's first action is to assess for a
DNR (Do Not Resuscitate) or AND (Allow Natural Death) order in the client's chart. If a valid DNR
order is present, CPR should not be initiated. If no such order exists, the nurse should begin CPR
immediately.
9. A nurse is reviewing the plan of care for a client who is at risk for falls. Which of the
following interventions should the nurse implement? (SATA)
A. Place the client in a room near the nurses' station.
B. Keep the bed in the lowest position.
, C. Encourage the use of a walker for ambulation.
D. Apply a vest restraint to keep the client in bed.
E. Instruct the client to use the call light for assistance.
Correct Answer: A, B, C, E
Rationale: Placing the client near the nurses' station allows for frequent observation.
Keeping the bed low reduces the risk of injury if a fall occurs. Encouraging the use of a walker
promotes safe mobility. Instructing the client to call for assistance is a crucial safety measure.
Restraints are a last resort and are not a routine intervention for fall prevention; they can
increase the risk of injury.
10. A nurse is prioritizing care for four clients. Which of the following clients should the nurse
assess first?
A. A client who is 2 days postoperative and requests pain medication.
B. A client who has a new onset of confusion and slurred speech.
C. A client who needs to be taught how to check their blood glucose.
D. A client who is scheduled for discharge in 1 hour.
Correct Answer: B
Rationale: The nurse should first assess the client with a new onset of confusion and slurred
speech. These are signs of a potential neurological emergency, such as a stroke. This client is the
most unstable and has the highest priority. The other clients have needs that are important but
not immediately life-threatening.
11. A nurse is preparing to transfer a client from the bed to a chair. Which of the following
actions should the nurse take to prevent injury to themselves?
A. Keep their feet close together.
B. Bend at the waist.
C. Use a mechanical lift if the client is unable to bear weight.
D. Twist their torso while lifting.
Correct Answer: C
Rationale: The nurse should use a mechanical lift for any client who cannot bear weight, as
this is the safest method for both the client and the nurse. Keeping feet close together and
bending at the waist are improper body mechanics. Twisting the torso while lifting greatly
increases the risk of back injury.
12. An AP reports to the nurse that a client's blood pressure is 88/50 mm Hg. Which of the
following actions should the nurse take first?
A. Ask the AP to recheck the blood pressure.
