ATI PN FUNDAMENTALS 2025 PROCTORED EXAM 70 QUESTIONS WITH DETAILED VERIFIED SOLUTIONS AND RATIONALE /A+ GRADE ASSURED

1. A nurse is preparing to administer a cleansing enema to a client. In which position should the nurse place the client? Answer: Left Sim's position with the right leg flexed. Rationale: This position allows the enema solution to flow by gravity along the natural curve of the sigmoid colon, enhancing effectiveness and comfort. 2. A nurse is caring for a client who requires a 24-hour urine specimen collection. What is the correct first action by the nurse? Answer: Discard the first voided urine. Rationale: The collection starts with an empty bladder. The first void is discarded, and the time is noted as the start time. All urine for the next 24 hours is then collected. 3. A nurse is implementing droplet precautions for a client with influenza. Which action must the nurse take? Answer: Wear a surgical mask when working within 3 feet of the client. Rationale: Droplet precautions require a mask for close contact (typically within 3 feet or 1 meter) to protect against large-particle droplets expelled during coughing, sneezing, or talking. 4. A nurse is assessing a client's pedal pulses. The pulse is difficult to palpate and rates a "1" on a 0-4+ scale. How should the nurse document this finding? Answer: Diminished or weak pulse. Rationale: A pulse amplitude of 1+ is described as diminished, weak, or barely palpable, indicating reduced blood flow to the area. 5. A client has a new prescription for a low-sodium diet. Which food choice by the client indicates an understanding of the teaching? Answer: Grilled chicken breast with steamed vegetables. Rationale: Fresh, unprocessed meats and vegetables are naturally lower in sodium compared to canned, processed, or pickled foods. 6. A nurse is delegating the task of vital sign measurement to an assistive personnel (AP) for a stable client. What instruction should the nurse provide? Answer: "Please measure the vital signs and report any abnormal findings to me immediately." Rationale: The nurse is responsible for assessment and interpretation of data. The AP can collect data but must report abnormalities for the nurse to analyze. 7. A nurse needs to use the nursing process to develop a care plan. What is the first step of this process? Answer: Assessment. Rationale: The nursing process follows the sequence of Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Assessment, the collection of data, must always come first. 8. A client is experiencing dysphagia following a stroke. Which nursing intervention is the highest priority during meals? Answer: Maintaining upright positioning at 90 degrees during and for 30 minutes after the meal. Rationale: This position uses gravity to facilitate swallowing and reduces the risk of aspiration, which is a life-threatening complication. 9. A nurse is preparing to administer an intramuscular (IM) injection using the Z-track method. What is the primary purpose of this technique? Answer: To prevent medication from leaking into the subcutaneous tissue. Rationale: The Z-track technique seals the medication deep within the muscle tissue, minimizing skin irritation and staining. 10. A client tells the nurse, "I'm in so much pain, I can't take it anymore." What is the nurse's most therapeutic response? Answer: "Tell me more about your pain." Rationale: This open-ended statement encourages the client to elaborate, allowing the nurse to perform a more comprehensive pain assessment. 11. A nurse is providing postmortem care. Which action is the priority? Answer: Identifying the body according to facility policy and preparing for transfer to the morgue. Rationale: Proper identification is a legal and ethical priority to prevent errors and ensure respect for the deceased. 12. A nurse is teaching a client about a new medication. Which statement by the client best demonstrates understanding of the teaching? Answer: The client states the medication's name, dose, reason for taking it, and potential side effects in their own words. Rationale: "Teach-back" or having the client explain in their own words is the most effective way to evaluate understanding. 13. A nurse is calculating a client's intake and output. The client consumed 4 oz of juice, 8 oz of soup, and 6 oz of water. What is the total fluid intake in milliliters? Answer: 540 mL. Rationale: 1 fluid ounce is approximately 30 mL. (4 oz + 8 oz + 6 oz) = 18 oz. 18 oz x 30 mL/oz = 540 mL. 14. A nurse is applying a nasal cannula for a client requiring oxygen therapy. What is a key safety precaution? Answer: Ensure the oxygen flowmeter is functioning and set at the prescribed liter flow before applying the cannula. Rationale: This prevents the delivery of an incorrect or hypoxic gas mixture to the client, which could cause harm.