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ATI Fundamentals CMS Proctored Exam 2025 –
130 Verified Questions with 100% Correct
Answers | Updated & Graded A+ Study Pack
1. A nurse is assessing a client’s respiratory status. Which action should the nurse take first?
A. Count the respiratory rate for 30 seconds and multiply by 2.
B. Auscultate lung sounds with a stethoscope.
C. Check the client’s oxygen saturation with a pulse oximeter.
D. Observe the client’s chest movement for symmetry.
Correct Answer: D
Rationale: Observing chest movement for symmetry is the first step in a respiratory
assessment, providing immediate visual cues about breathing patterns. Counting
respirations, auscultating, and checking oxygen saturation follow in a systematic
approach.
2. A nurse is preparing to administer an intramuscular injection. Which site is most
appropriate for an adult client?
A. Dorsogluteal
B. Vastus lateralis
C. Rectus femoris
D. Deltoid
Correct Answer: B
Rationale: The vastus lateralis is preferred for IM injections in adults due to its large
muscle mass and low risk of nerve injury. The dorsogluteal site risks sciatic nerve
damage, while deltoid and rectus femoris are for smaller volumes.
3. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Evaluating a client’s response to pain medication
B. Assisting a client with ambulation to the bathroom
C. Developing a plan of care for a client with diabetes
D. Administering a subcutaneous insulin injection
Correct Answer: B
Rationale: Assisting with ambulation is within the AP’s scope. Evaluating, planning care,
and administering injections require nursing judgment and are not delegable.
4. A client reports chest pain that worsens with inspiration. The nurse auscultates a high-
pitched scratching sound during systole and diastole at the left sternal border. What
should the nurse document?
A. Murmur
B. Third heart sound
C. Pericardial friction rub
D. Audible click
Correct Answer: C
, 2
Rationale: A high-pitched scratching sound at the left sternal border indicates a
pericardial friction rub, often due to pericarditis. Murmurs are whooshing, third heart
sounds are low-pitched, and clicks relate to valve issues.
5. A nurse is teaching a client about advance directives. Which statement by the client
indicates understanding?
A. “I need a lawyer to complete my advance directives.”
B. “My advance directives can specify my treatment preferences.”
C. “Advance directives are only for clients with terminal illnesses.”
D. “I must update my advance directives every year.”
Correct Answer: B
Rationale: Advance directives allow clients to specify treatment preferences. A lawyer is
not required, they apply to all adults, and updates are as needed, not annually.
6. A nurse is measuring a client’s blood pressure in the lower extremity. Which action is
correct?
A. Place the cuff 3 inches above the dorsalis pedis artery.
B. Auscultate the blood pressure at the popliteal artery.
C. Position the client sitting on the bed’s edge.
D. Place the bladder of the cuff over the posterior thigh.
Correct Answer: D
Rationale: The cuff’s bladder is placed over the posterior thigh for lower extremity blood
pressure, with the popliteal artery auscultated. The client is supine or prone, not sitting.
7. A nurse is caring for a client with a nasogastric (NG) tube. Which action prevents
aspiration during feeding?
A. Administer the formula at room temperature.
B. Keep the head of the bed elevated at least 30 degrees.
C. Flush the tube with 10 mL of water before feeding.
D. Check residual volume every 8 hours.
Correct Answer: B
Rationale: Elevating the bed at least 30 degrees reduces aspiration risk by aiding gastric
emptying. Room-temperature formula prevents cramping, flushing ensures patency, and
residual checks monitor digestion.
8. A nurse is performing tracheostomy suctioning. Which action is appropriate?
A. Use a suction pressure of 200 mmHg.
B. Suction for 20 seconds per pass.
C. Pre-oxygenate with 100% oxygen.
D. Apply suction while inserting the catheter.
Correct Answer: C
Rationale: Pre-oxygenating prevents hypoxemia. Suction pressure should be 120–150
mmHg, suctioning lasts 10–15 seconds, and suction is applied only during withdrawal.
9. A nurse is assisting a client with a stage 2 pressure injury. Which intervention is priority?
A. Apply a hydrocolloid dressing.
B. Reposition the client every 2 hours.
C. Administer an oral antibiotic.
D. Measure the wound daily.
Correct Answer: B
Rationale: Repositioning every 2 hours relieves pressure, preventing further damage.
, 3
Dressings aid healing, antibiotics treat infection, and measurement monitors progress, but
repositioning is priority.
10. A nurse is inserting an indwelling urinary catheter for an older adult. Which technique is
correct?
A. Insert the catheter at a 45-degree angle.
B. Place the client’s arm in a dependent position.
C. Inflate the balloon before advancing the catheter.
D. Use sterile gloves during insertion.
Correct Answer: D
Rationale: Sterile gloves maintain asepsis. The catheter is inserted at a 10–30-degree
angle, arm position is irrelevant, and the balloon is inflated after placement.
11. A nurse is teaching a client about using an incentive spirometer. Which instruction is
correct?
A. Use the device in a supine position.
B. Inhale slowly and deeply through the mouthpiece.
C. Hold the breath for 2 seconds after inhalation.
D. Exhale forcefully into the device.
Correct Answer: B
Rationale: Inhaling slowly and deeply maximizes lung expansion. The client should be
semi-Fowler’s, hold the breath for 3–5 seconds, and exhale normally.
12. A nurse is caring for a client with a wound healing by secondary intention. What is a
characteristic of this healing process?
A. Minimal scarring
B. Rapid healing time
C. Widely separated wound edges
D. No risk of infection
Correct Answer: C
Rationale: Secondary intention involves widely separated edges, leading to longer
healing, increased infection risk, and scarring.
13. A nurse is preparing to administer otic medication to an adult client. Which action is
correct?
A. Pull the ear downward and back.
B. Instill drops and press gently on the tragus.
C. Keep the client supine during administration.
D. Warm the medication to body temperature after instillation.
Correct Answer: B
Rationale: Pressing the tragus aids medication absorption. The ear is pulled upward and
back for adults, the client is side-lying, and medication is warmed before instillation.
14. A nurse is assessing a client with fluid volume deficit. Which finding is expected?
A. Bounding pulses
B. Increased urine output
C. Dry mucous membranes
D. Elevated blood pressure
Correct Answer: C
Rationale: Dry mucous membranes indicate dehydration. Bounding pulses, increased
urine output, and elevated blood pressure suggest fluid overload.
ATI Fundamentals CMS Proctored Exam 2025 –
130 Verified Questions with 100% Correct
Answers | Updated & Graded A+ Study Pack
1. A nurse is assessing a client’s respiratory status. Which action should the nurse take first?
A. Count the respiratory rate for 30 seconds and multiply by 2.
B. Auscultate lung sounds with a stethoscope.
C. Check the client’s oxygen saturation with a pulse oximeter.
D. Observe the client’s chest movement for symmetry.
Correct Answer: D
Rationale: Observing chest movement for symmetry is the first step in a respiratory
assessment, providing immediate visual cues about breathing patterns. Counting
respirations, auscultating, and checking oxygen saturation follow in a systematic
approach.
2. A nurse is preparing to administer an intramuscular injection. Which site is most
appropriate for an adult client?
A. Dorsogluteal
B. Vastus lateralis
C. Rectus femoris
D. Deltoid
Correct Answer: B
Rationale: The vastus lateralis is preferred for IM injections in adults due to its large
muscle mass and low risk of nerve injury. The dorsogluteal site risks sciatic nerve
damage, while deltoid and rectus femoris are for smaller volumes.
3. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Evaluating a client’s response to pain medication
B. Assisting a client with ambulation to the bathroom
C. Developing a plan of care for a client with diabetes
D. Administering a subcutaneous insulin injection
Correct Answer: B
Rationale: Assisting with ambulation is within the AP’s scope. Evaluating, planning care,
and administering injections require nursing judgment and are not delegable.
4. A client reports chest pain that worsens with inspiration. The nurse auscultates a high-
pitched scratching sound during systole and diastole at the left sternal border. What
should the nurse document?
A. Murmur
B. Third heart sound
C. Pericardial friction rub
D. Audible click
Correct Answer: C
, 2
Rationale: A high-pitched scratching sound at the left sternal border indicates a
pericardial friction rub, often due to pericarditis. Murmurs are whooshing, third heart
sounds are low-pitched, and clicks relate to valve issues.
5. A nurse is teaching a client about advance directives. Which statement by the client
indicates understanding?
A. “I need a lawyer to complete my advance directives.”
B. “My advance directives can specify my treatment preferences.”
C. “Advance directives are only for clients with terminal illnesses.”
D. “I must update my advance directives every year.”
Correct Answer: B
Rationale: Advance directives allow clients to specify treatment preferences. A lawyer is
not required, they apply to all adults, and updates are as needed, not annually.
6. A nurse is measuring a client’s blood pressure in the lower extremity. Which action is
correct?
A. Place the cuff 3 inches above the dorsalis pedis artery.
B. Auscultate the blood pressure at the popliteal artery.
C. Position the client sitting on the bed’s edge.
D. Place the bladder of the cuff over the posterior thigh.
Correct Answer: D
Rationale: The cuff’s bladder is placed over the posterior thigh for lower extremity blood
pressure, with the popliteal artery auscultated. The client is supine or prone, not sitting.
7. A nurse is caring for a client with a nasogastric (NG) tube. Which action prevents
aspiration during feeding?
A. Administer the formula at room temperature.
B. Keep the head of the bed elevated at least 30 degrees.
C. Flush the tube with 10 mL of water before feeding.
D. Check residual volume every 8 hours.
Correct Answer: B
Rationale: Elevating the bed at least 30 degrees reduces aspiration risk by aiding gastric
emptying. Room-temperature formula prevents cramping, flushing ensures patency, and
residual checks monitor digestion.
8. A nurse is performing tracheostomy suctioning. Which action is appropriate?
A. Use a suction pressure of 200 mmHg.
B. Suction for 20 seconds per pass.
C. Pre-oxygenate with 100% oxygen.
D. Apply suction while inserting the catheter.
Correct Answer: C
Rationale: Pre-oxygenating prevents hypoxemia. Suction pressure should be 120–150
mmHg, suctioning lasts 10–15 seconds, and suction is applied only during withdrawal.
9. A nurse is assisting a client with a stage 2 pressure injury. Which intervention is priority?
A. Apply a hydrocolloid dressing.
B. Reposition the client every 2 hours.
C. Administer an oral antibiotic.
D. Measure the wound daily.
Correct Answer: B
Rationale: Repositioning every 2 hours relieves pressure, preventing further damage.
, 3
Dressings aid healing, antibiotics treat infection, and measurement monitors progress, but
repositioning is priority.
10. A nurse is inserting an indwelling urinary catheter for an older adult. Which technique is
correct?
A. Insert the catheter at a 45-degree angle.
B. Place the client’s arm in a dependent position.
C. Inflate the balloon before advancing the catheter.
D. Use sterile gloves during insertion.
Correct Answer: D
Rationale: Sterile gloves maintain asepsis. The catheter is inserted at a 10–30-degree
angle, arm position is irrelevant, and the balloon is inflated after placement.
11. A nurse is teaching a client about using an incentive spirometer. Which instruction is
correct?
A. Use the device in a supine position.
B. Inhale slowly and deeply through the mouthpiece.
C. Hold the breath for 2 seconds after inhalation.
D. Exhale forcefully into the device.
Correct Answer: B
Rationale: Inhaling slowly and deeply maximizes lung expansion. The client should be
semi-Fowler’s, hold the breath for 3–5 seconds, and exhale normally.
12. A nurse is caring for a client with a wound healing by secondary intention. What is a
characteristic of this healing process?
A. Minimal scarring
B. Rapid healing time
C. Widely separated wound edges
D. No risk of infection
Correct Answer: C
Rationale: Secondary intention involves widely separated edges, leading to longer
healing, increased infection risk, and scarring.
13. A nurse is preparing to administer otic medication to an adult client. Which action is
correct?
A. Pull the ear downward and back.
B. Instill drops and press gently on the tragus.
C. Keep the client supine during administration.
D. Warm the medication to body temperature after instillation.
Correct Answer: B
Rationale: Pressing the tragus aids medication absorption. The ear is pulled upward and
back for adults, the client is side-lying, and medication is warmed before instillation.
14. A nurse is assessing a client with fluid volume deficit. Which finding is expected?
A. Bounding pulses
B. Increased urine output
C. Dry mucous membranes
D. Elevated blood pressure
Correct Answer: C
Rationale: Dry mucous membranes indicate dehydration. Bounding pulses, increased
urine output, and elevated blood pressure suggest fluid overload.
