ATI Fundamentals CMS Proctored Exam
2025 – 100+ Actual Questions with Verified
Correct Answers | Updated Test Bank |
Graded A+
Question 1
A nurse is preparing to administer a medication via intramuscular (IM) injection to a
client. Which action should the nurse take first?
A. Check the medication administration record (MAR).
B. Draw up the medication into the syringe.
C. Select the appropriate needle size.
D. Cleanse the injection site with alcohol.
Correct Answer: A
Rationale:
A (Correct): Checking the MAR first ensures the nurse verifies the correct medication, dose,
route, time, and client, adhering to the "five rights" of medication administration to
prevent errors.
B (Incorrect): Drawing up the medication before verifying the order risks administering the
wrong drug or dose.
C (Incorrect): Selecting the needle size is important but follows verification of the order to
ensure the correct procedure.
D (Incorrect): Cleansing the site is a later step after confirming the medication and preparing
the syringe.
Question 2
A nurse is assessing a client’s blood pressure in the lower extremity. Where should the
nurse place the bladder of the cuff?
A. Over the dorsalis pedis artery.
B. 7.6 cm (3 in) above the popliteal artery.
C. Over the posterior aspect of the thigh.
D. Over the anterior aspect of the ankle.
Correct Answer: C
Rationale:
, A (Incorrect): The dorsalis pedis artery is used for pulse assessment, not blood pressure cuff
placement.
B (Incorrect): Placing the cuff 7.6 cm above the popliteal artery is incorrect; the bladder
should be centered over the artery.
C (Correct): The bladder of the cuff should be placed over the posterior aspect of the thigh
to compress the popliteal artery accurately for a lower extremity blood pressure reading.
D (Incorrect): The anterior ankle is not an appropriate site for blood pressure measurement.
Question 3
A nurse is teaching a group of newly licensed nurses about adult CPR. What is the first
action to take when initiating CPR?
A. Call for help.
B. Check for a pulse.
C. Begin chest compressions.
D. Open the airway.
Correct Answer: B
Rationale:
A (Incorrect): Calling for help is necessary but follows confirming unresponsiveness and
pulselessness.
B (Correct): Checking for a pulse determines if CPR is needed, as per American Heart
Association guidelines.
C (Incorrect): Chest compressions begin only after confirming no pulse.
D (Incorrect): Opening the airway follows pulse assessment if CPR is required.
Question 4
A nurse is collecting a stool specimen for ova and parasites from a client with diarrhea.
Which action should the nurse take?
A. Instruct the client to defecate into the toilet bowl.
B. Transfer the specimen to a sterile container.
C. Refrigerate the collected specimen.
D. Place the specimen in a biohazard bag for transport.
Correct Answer: D
Rationale:
, A (Incorrect): Defecating into the toilet risks contamination by water; a clean container or
bedpan should be used.
B (Incorrect): A clean, not sterile, container is required for stool specimens to avoid
unnecessary cost and complexity.
C (Incorrect): The specimen should be sent to the lab immediately to prevent degradation,
not refrigerated.
D (Correct): Placing the specimen in a biohazard bag ensures safe transport to the
laboratory, maintaining infection control.
Question 5
A nurse is assessing a client who reports chest pain that worsens with inspiration. The
nurse auscultates a high-pitched scratching sound during systole and diastole at the left
sternal border. Which heart sound should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D
Rationale:
A (Incorrect): An audible click is associated with valve prolapse, not chest pain with
inspiration.
B (Incorrect): A murmur is a whooshing sound from turbulent blood flow, not a scratching
sound.
C (Incorrect): A third heart sound (S3) is a low-pitched gallop, not a high-pitched scratch.
D (Correct): A pericardial friction rub is a high-pitched scratching sound heard in
pericarditis, worsened by inspiration.
Question 6
A nurse is preparing to administer an otic medication to an adult client. Which action
should the nurse take?
A. Pull the ear down and back.
B. Instill the medication at a 90-degree angle.
C. Keep the client supine during administration.
D. Pull the ear up and back.
, Correct Answer: D
Rationale:
A (Incorrect): Pulling the ear down and back is used for children, not adults, to straighten
the ear canal.
B (Incorrect): Instilling at a 90-degree angle is not standard; drops are instilled gently along
the canal.
C (Incorrect): The client should be side-lying with the affected ear up, not supine, for 2–5
minutes post-administration.
D (Correct): Pulling the ear up and back straightens the ear canal in adults for effective otic
medication delivery.
Question 7
A nurse is caring for a client with a nasogastric (NG) tube for enteral feeding. Which action
reduces the risk of aspiration?
A. Administer the feeding at room temperature.
B. Keep the head of the bed elevated at least 30 degrees.
C. Flush the tube with cold water before feeding.
D. Check residual volume every 8 hours.
Correct Answer: B
Rationale:
A (Incorrect): Room-temperature formula prevents cramping but does not directly reduce
aspiration risk.
B (Correct): Elevating the head of the bed ≥30 degrees prevents reflux and aspiration during
NG feeding.
C (Incorrect): Flushing with cold water is not standard; warm or room-temperature sterile
water is used.
D (Incorrect): Checking residual volume monitors tolerance but does not directly prevent
aspiration.
Question 8
A nurse is performing tracheostomy suctioning. Which action should the nurse take?
A. Use a suction catheter twice the size of the lumen.
B. Set suction pressure to 200 mmHg.
2025 – 100+ Actual Questions with Verified
Correct Answers | Updated Test Bank |
Graded A+
Question 1
A nurse is preparing to administer a medication via intramuscular (IM) injection to a
client. Which action should the nurse take first?
A. Check the medication administration record (MAR).
B. Draw up the medication into the syringe.
C. Select the appropriate needle size.
D. Cleanse the injection site with alcohol.
Correct Answer: A
Rationale:
A (Correct): Checking the MAR first ensures the nurse verifies the correct medication, dose,
route, time, and client, adhering to the "five rights" of medication administration to
prevent errors.
B (Incorrect): Drawing up the medication before verifying the order risks administering the
wrong drug or dose.
C (Incorrect): Selecting the needle size is important but follows verification of the order to
ensure the correct procedure.
D (Incorrect): Cleansing the site is a later step after confirming the medication and preparing
the syringe.
Question 2
A nurse is assessing a client’s blood pressure in the lower extremity. Where should the
nurse place the bladder of the cuff?
A. Over the dorsalis pedis artery.
B. 7.6 cm (3 in) above the popliteal artery.
C. Over the posterior aspect of the thigh.
D. Over the anterior aspect of the ankle.
Correct Answer: C
Rationale:
, A (Incorrect): The dorsalis pedis artery is used for pulse assessment, not blood pressure cuff
placement.
B (Incorrect): Placing the cuff 7.6 cm above the popliteal artery is incorrect; the bladder
should be centered over the artery.
C (Correct): The bladder of the cuff should be placed over the posterior aspect of the thigh
to compress the popliteal artery accurately for a lower extremity blood pressure reading.
D (Incorrect): The anterior ankle is not an appropriate site for blood pressure measurement.
Question 3
A nurse is teaching a group of newly licensed nurses about adult CPR. What is the first
action to take when initiating CPR?
A. Call for help.
B. Check for a pulse.
C. Begin chest compressions.
D. Open the airway.
Correct Answer: B
Rationale:
A (Incorrect): Calling for help is necessary but follows confirming unresponsiveness and
pulselessness.
B (Correct): Checking for a pulse determines if CPR is needed, as per American Heart
Association guidelines.
C (Incorrect): Chest compressions begin only after confirming no pulse.
D (Incorrect): Opening the airway follows pulse assessment if CPR is required.
Question 4
A nurse is collecting a stool specimen for ova and parasites from a client with diarrhea.
Which action should the nurse take?
A. Instruct the client to defecate into the toilet bowl.
B. Transfer the specimen to a sterile container.
C. Refrigerate the collected specimen.
D. Place the specimen in a biohazard bag for transport.
Correct Answer: D
Rationale:
, A (Incorrect): Defecating into the toilet risks contamination by water; a clean container or
bedpan should be used.
B (Incorrect): A clean, not sterile, container is required for stool specimens to avoid
unnecessary cost and complexity.
C (Incorrect): The specimen should be sent to the lab immediately to prevent degradation,
not refrigerated.
D (Correct): Placing the specimen in a biohazard bag ensures safe transport to the
laboratory, maintaining infection control.
Question 5
A nurse is assessing a client who reports chest pain that worsens with inspiration. The
nurse auscultates a high-pitched scratching sound during systole and diastole at the left
sternal border. Which heart sound should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Correct Answer: D
Rationale:
A (Incorrect): An audible click is associated with valve prolapse, not chest pain with
inspiration.
B (Incorrect): A murmur is a whooshing sound from turbulent blood flow, not a scratching
sound.
C (Incorrect): A third heart sound (S3) is a low-pitched gallop, not a high-pitched scratch.
D (Correct): A pericardial friction rub is a high-pitched scratching sound heard in
pericarditis, worsened by inspiration.
Question 6
A nurse is preparing to administer an otic medication to an adult client. Which action
should the nurse take?
A. Pull the ear down and back.
B. Instill the medication at a 90-degree angle.
C. Keep the client supine during administration.
D. Pull the ear up and back.
, Correct Answer: D
Rationale:
A (Incorrect): Pulling the ear down and back is used for children, not adults, to straighten
the ear canal.
B (Incorrect): Instilling at a 90-degree angle is not standard; drops are instilled gently along
the canal.
C (Incorrect): The client should be side-lying with the affected ear up, not supine, for 2–5
minutes post-administration.
D (Correct): Pulling the ear up and back straightens the ear canal in adults for effective otic
medication delivery.
Question 7
A nurse is caring for a client with a nasogastric (NG) tube for enteral feeding. Which action
reduces the risk of aspiration?
A. Administer the feeding at room temperature.
B. Keep the head of the bed elevated at least 30 degrees.
C. Flush the tube with cold water before feeding.
D. Check residual volume every 8 hours.
Correct Answer: B
Rationale:
A (Incorrect): Room-temperature formula prevents cramping but does not directly reduce
aspiration risk.
B (Correct): Elevating the head of the bed ≥30 degrees prevents reflux and aspiration during
NG feeding.
C (Incorrect): Flushing with cold water is not standard; warm or room-temperature sterile
water is used.
D (Incorrect): Checking residual volume monitors tolerance but does not directly prevent
aspiration.
Question 8
A nurse is performing tracheostomy suctioning. Which action should the nurse take?
A. Use a suction catheter twice the size of the lumen.
B. Set suction pressure to 200 mmHg.
