ATI ATI FUNDAMENTALS PROCTORED 2024
NEWEST ACTUAL EXAM ALL QUESTIONS AND
CORRECT ANSWERS|ALREADY GRADED A+
1. A nurse is preparing to administer a blood transfusion. Which of the following actions is most
important to prevent a transfusion reaction?
A. Verify the patient's identity using two identifiers before starting the transfusion.
B. Prime the IV tubing with 0.9% sodium chloride and use a dedicated Y-set.
C. Check the patient's vital signs every 15 minutes during the first hour.
D. Obtain a baseline complete blood count (CBC) before the transfusion.
Answer: A
Rationale: Verifying patient identity with two identifiers (e.g., name and date of birth) is the primary
safety check to ensure the correct blood product is administered, reducing the risk of ABO
incompatibility. While priming with saline and monitoring vital signs are important, they are secondary
to correct identification.
2. A nurse is assessing a patient who has a nasogastric (NG) tube set to low intermittent suction.
The nurse notes that the patient's gastric output has decreased from 150 mL to 30 mL over the
past 4 hours. Which of the following actions should the nurse take first?
A. Irrigate the NG tube with 30 mL of 0.9% sodium chloride.
B. Notify the provider of the decreased output.
C. Check the placement of the NG tube by measuring the external length and verifying pH of aspirate.
D. Reposition the patient onto their left side.
Answer: C
Rationale: A sudden decrease in output may indicate tube displacement or blockage. The nurse should
first verify tube placement (e.g., check external length, pH of aspirate) before any interventions.
Irrigation or repositioning without confirming placement could cause aspiration if the tube is dislodged.
3. A nurse is teaching a patient with a new diagnosis of type 2 diabetes mellitus about foot care.
Which statement by the patient indicates a need for further teaching?
A. I will inspect my feet daily using a mirror.
B. I should wear cotton socks and change them if they become damp.
C. I can soak my feet in warm water for 30 minutes each evening.
D. I will cut my toenails straight across and file the edges.
Answer: C
Rationale: Soaking feet for prolonged periods can lead to maceration and skin breakdown, increasing
infection risk. Patients with diabetes should wash feet with mild soap and lukewarm water, dry
thoroughly, and avoid soaking. The other statements are correct.
Page 1
,4. A nurse is caring for a patient who has a chest tube connected to a dry suction water seal
drainage system. The nurse notes continuous bubbling in the water seal chamber. Which of the
following actions should the nurse take?
A. Increase the suction pressure until bubbling stops.
B. Check the system for an air leak.
C. Clamp the chest tube near the insertion site.
D. Replace the drainage system immediately.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak (either from the patient
or the system). The nurse should assess the system for leaks (e.g., loose connections, cracks). Clamping
is dangerous and only done temporarily to locate a leak. Increasing suction or replacing the system is
not a first step.
5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). The patient's IV is
infusing 0.9% sodium chloride at 100 mL/hr. Which of the following actions should the nurse take?
A. Use the existing IV tubing and prime with the blood product.
B. Obtain Y-tubing with an in-line filter and prime with 0.9% sodium chloride.
C. Add the blood to the existing IV bag of normal saline.
D. Administer the blood through a separate peripheral IV line without a filter.
Answer: B
Rationale: Blood products require Y-tubing with a filter to remove clots and debris. The tubing should be
primed with 0.9% sodium chloride (not dextrose solutions) to prevent hemolysis. Adding blood to an IV
bag is not recommended due to risk of contamination and inaccurate rate control.
6. A nurse is assessing a patient who has a stage 3 pressure ulcer on the sacrum. Which finding
should the nurse report to the provider?
A. Wound bed with 50% red granulation tissue and 50% yellow slough.
B. Periwound skin that is intact and non-erythematous.
C. Purulent drainage with a foul odor and increased warmth around the wound.
D. Pain level of 3 on a 0-10 scale during dressing changes.
Answer: C
Rationale: Purulent drainage, foul odor, and warmth are signs of infection, which require immediate
reporting and possible wound culture. Granulation tissue and slough are expected in a healing stage 3
ulcer. Intact periwound skin and manageable pain are normal findings.
7. A nurse is administering a continuous enteral feeding via a nasogastric tube. The patient's
gastric residual volume (GRV) is 350 mL. Which of the following actions should the nurse take?
A. Discard the residual and continue the feeding at the same rate.
B. Hold the feeding and recheck the GRV in 2 hours.
C. Return the residual and decrease the feeding rate by 20 mL/hr.
D. Replace the residual and continue the feeding as prescribed.
Answer: B
Page 2
,Rationale: A GRV > 250 mL indicates delayed gastric emptying and risk of aspiration. The nurse should hold the feeding
and recheck GRV in 1-2 hours. If high residuals persist, the provider may need to adjust the rate or consider prokinetics.
Discarding or replacing residual without reassessment is not appropriate.
8. A nurse is preparing to administer a medication via a nasogastric tube. The medication is an
enteric-coated tablet. Which of the following actions should the nurse take?
A. Crush the tablet and mix with 30 mL of water.
B. Dissolve the tablet in 10 mL of warm water and administer.
C. Contact the pharmacist for a liquid formulation.
D. Open the capsule and sprinkle the contents into the tube.
Answer: C
Rationale: Enteric-coated tablets are designed to resist dissolution in the stomach; crushing them can
lead to altered absorption and irritation. The nurse should request a liquid formulation or a different
dosage form. Crushing or dissolving the tablet is contraindicated.
9. A nurse is caring for a patient who is receiving a continuous heparin infusion. The patient's
activated partial thromboplastin time (aPTT) is 120 seconds. The therapeutic range is 60-80
seconds. Which of the following actions should the nurse anticipate?
A. Increase the heparin infusion rate by 100 units/hr.
B. Administer protamine sulfate immediately.
C. Decrease the heparin infusion rate per protocol.
D. Continue the infusion at the current rate.
Answer: C
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating increased bleeding risk.
The nurse should decrease the infusion rate per protocol (often hold and then restart at a lower rate).
Protamine is an antidote for severe bleeding, not for a mildly elevated aPTT without bleeding.
10. A nurse is providing discharge teaching to a patient who is prescribed warfarin. Which of the
following statements by the patient indicates an understanding of the teaching?
A. I will take aspirin if I have a headache.
B. I should avoid eating green leafy vegetables.
C. I will use an electric razor for shaving.
D. I can take over-the-counter ibuprofen for joint pain.
Answer: C
Rationale: Patients on warfarin are at increased risk for bleeding; using an electric razor reduces the risk
of cuts. Aspirin and NSAIDs (ibuprofen) increase bleeding risk and should be avoided. Green leafy
vegetables are high in vitamin K, which can interfere with warfarin, but patients should maintain
consistent intake, not avoid them entirely.
11. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes that the patient's oxygen saturation is 89%. Which intervention
should the nurse implement first?
Page 3
, A. Increase the oxygen flow rate to 4 L/min and reassess in 15 minutes.
B. Encourage the patient to cough and deep breathe.
C. Assess the patient's respiratory rate, rhythm, and effort.
D. Apply a non-rebreather mask at 10 L/min.
Answer: C
Rationale: The nurse should first assess the patient's respiratory status, including rate, rhythm, and
effort, to identify potential causes of desaturation. Increasing oxygen without assessment may mask
underlying issues. Encouraging coughing/deep breathing is beneficial but not the first priority. A
non-rebreather mask is not indicated for COPD patients due to risk of oxygen-induced hypoventilation.
12. A nurse is preparing to administer a blood transfusion to a patient. Which action is most
important to prevent a transfusion reaction?
A. Verify the patient's identity using two identifiers.
B. Check the blood product expiration date.
C. Prime the tubing with 0.9% normal saline.
D. Obtain baseline vital signs within 30 minutes of transfusion.
Answer: A
Rationale: The most critical step in preventing a transfusion reaction is verifying the patient's identity
with two identifiers to ensure the correct blood product is administered to the correct patient. Checking
expiration, priming with saline, and obtaining baseline vitals are important but secondary to proper
identification.
13. A nurse is assessing a patient who has a nasogastric (NG) tube set to low intermittent suction.
Which finding indicates that the tube may be obstructed?
A. The patient reports nausea and abdominal distention.
B. The suction canister contains 100 mL of greenish fluid over 8 hours.
C. The pH of aspirated fluid is 3.
D. The nurse is unable to aspirate gastric contents.
Answer: D
Rationale: Inability to aspirate gastric contents suggests the tube is not patent, possibly due to
obstruction or malposition. Nausea and distention may indicate obstruction but are subjective. A low
output over 8 hours could be normal. A pH of 3 confirms gastric placement but does not assess patency.
14. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving a continuous heparin
infusion. The aPTT result is 120 seconds. What is the nurse's priority action?
A. Increase the heparin infusion rate per protocol.
B. Stop the infusion and notify the healthcare provider.
C. Administer protamine sulfate immediately.
D. Document the result and continue monitoring.
Answer: B
Rationale: An aPTT of 120 seconds is significantly above the therapeutic range (typically 60-80 seconds),
indicating a high risk of bleeding. The nurse should stop the infusion and notify the provider for dose
adjustment. Increasing the rate would worsen the situation. Protamine sulfate is an antidote but should
Page 4
NEWEST ACTUAL EXAM ALL QUESTIONS AND
CORRECT ANSWERS|ALREADY GRADED A+
1. A nurse is preparing to administer a blood transfusion. Which of the following actions is most
important to prevent a transfusion reaction?
A. Verify the patient's identity using two identifiers before starting the transfusion.
B. Prime the IV tubing with 0.9% sodium chloride and use a dedicated Y-set.
C. Check the patient's vital signs every 15 minutes during the first hour.
D. Obtain a baseline complete blood count (CBC) before the transfusion.
Answer: A
Rationale: Verifying patient identity with two identifiers (e.g., name and date of birth) is the primary
safety check to ensure the correct blood product is administered, reducing the risk of ABO
incompatibility. While priming with saline and monitoring vital signs are important, they are secondary
to correct identification.
2. A nurse is assessing a patient who has a nasogastric (NG) tube set to low intermittent suction.
The nurse notes that the patient's gastric output has decreased from 150 mL to 30 mL over the
past 4 hours. Which of the following actions should the nurse take first?
A. Irrigate the NG tube with 30 mL of 0.9% sodium chloride.
B. Notify the provider of the decreased output.
C. Check the placement of the NG tube by measuring the external length and verifying pH of aspirate.
D. Reposition the patient onto their left side.
Answer: C
Rationale: A sudden decrease in output may indicate tube displacement or blockage. The nurse should
first verify tube placement (e.g., check external length, pH of aspirate) before any interventions.
Irrigation or repositioning without confirming placement could cause aspiration if the tube is dislodged.
3. A nurse is teaching a patient with a new diagnosis of type 2 diabetes mellitus about foot care.
Which statement by the patient indicates a need for further teaching?
A. I will inspect my feet daily using a mirror.
B. I should wear cotton socks and change them if they become damp.
C. I can soak my feet in warm water for 30 minutes each evening.
D. I will cut my toenails straight across and file the edges.
Answer: C
Rationale: Soaking feet for prolonged periods can lead to maceration and skin breakdown, increasing
infection risk. Patients with diabetes should wash feet with mild soap and lukewarm water, dry
thoroughly, and avoid soaking. The other statements are correct.
Page 1
,4. A nurse is caring for a patient who has a chest tube connected to a dry suction water seal
drainage system. The nurse notes continuous bubbling in the water seal chamber. Which of the
following actions should the nurse take?
A. Increase the suction pressure until bubbling stops.
B. Check the system for an air leak.
C. Clamp the chest tube near the insertion site.
D. Replace the drainage system immediately.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak (either from the patient
or the system). The nurse should assess the system for leaks (e.g., loose connections, cracks). Clamping
is dangerous and only done temporarily to locate a leak. Increasing suction or replacing the system is
not a first step.
5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). The patient's IV is
infusing 0.9% sodium chloride at 100 mL/hr. Which of the following actions should the nurse take?
A. Use the existing IV tubing and prime with the blood product.
B. Obtain Y-tubing with an in-line filter and prime with 0.9% sodium chloride.
C. Add the blood to the existing IV bag of normal saline.
D. Administer the blood through a separate peripheral IV line without a filter.
Answer: B
Rationale: Blood products require Y-tubing with a filter to remove clots and debris. The tubing should be
primed with 0.9% sodium chloride (not dextrose solutions) to prevent hemolysis. Adding blood to an IV
bag is not recommended due to risk of contamination and inaccurate rate control.
6. A nurse is assessing a patient who has a stage 3 pressure ulcer on the sacrum. Which finding
should the nurse report to the provider?
A. Wound bed with 50% red granulation tissue and 50% yellow slough.
B. Periwound skin that is intact and non-erythematous.
C. Purulent drainage with a foul odor and increased warmth around the wound.
D. Pain level of 3 on a 0-10 scale during dressing changes.
Answer: C
Rationale: Purulent drainage, foul odor, and warmth are signs of infection, which require immediate
reporting and possible wound culture. Granulation tissue and slough are expected in a healing stage 3
ulcer. Intact periwound skin and manageable pain are normal findings.
7. A nurse is administering a continuous enteral feeding via a nasogastric tube. The patient's
gastric residual volume (GRV) is 350 mL. Which of the following actions should the nurse take?
A. Discard the residual and continue the feeding at the same rate.
B. Hold the feeding and recheck the GRV in 2 hours.
C. Return the residual and decrease the feeding rate by 20 mL/hr.
D. Replace the residual and continue the feeding as prescribed.
Answer: B
Page 2
,Rationale: A GRV > 250 mL indicates delayed gastric emptying and risk of aspiration. The nurse should hold the feeding
and recheck GRV in 1-2 hours. If high residuals persist, the provider may need to adjust the rate or consider prokinetics.
Discarding or replacing residual without reassessment is not appropriate.
8. A nurse is preparing to administer a medication via a nasogastric tube. The medication is an
enteric-coated tablet. Which of the following actions should the nurse take?
A. Crush the tablet and mix with 30 mL of water.
B. Dissolve the tablet in 10 mL of warm water and administer.
C. Contact the pharmacist for a liquid formulation.
D. Open the capsule and sprinkle the contents into the tube.
Answer: C
Rationale: Enteric-coated tablets are designed to resist dissolution in the stomach; crushing them can
lead to altered absorption and irritation. The nurse should request a liquid formulation or a different
dosage form. Crushing or dissolving the tablet is contraindicated.
9. A nurse is caring for a patient who is receiving a continuous heparin infusion. The patient's
activated partial thromboplastin time (aPTT) is 120 seconds. The therapeutic range is 60-80
seconds. Which of the following actions should the nurse anticipate?
A. Increase the heparin infusion rate by 100 units/hr.
B. Administer protamine sulfate immediately.
C. Decrease the heparin infusion rate per protocol.
D. Continue the infusion at the current rate.
Answer: C
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating increased bleeding risk.
The nurse should decrease the infusion rate per protocol (often hold and then restart at a lower rate).
Protamine is an antidote for severe bleeding, not for a mildly elevated aPTT without bleeding.
10. A nurse is providing discharge teaching to a patient who is prescribed warfarin. Which of the
following statements by the patient indicates an understanding of the teaching?
A. I will take aspirin if I have a headache.
B. I should avoid eating green leafy vegetables.
C. I will use an electric razor for shaving.
D. I can take over-the-counter ibuprofen for joint pain.
Answer: C
Rationale: Patients on warfarin are at increased risk for bleeding; using an electric razor reduces the risk
of cuts. Aspirin and NSAIDs (ibuprofen) increase bleeding risk and should be avoided. Green leafy
vegetables are high in vitamin K, which can interfere with warfarin, but patients should maintain
consistent intake, not avoid them entirely.
11. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes that the patient's oxygen saturation is 89%. Which intervention
should the nurse implement first?
Page 3
, A. Increase the oxygen flow rate to 4 L/min and reassess in 15 minutes.
B. Encourage the patient to cough and deep breathe.
C. Assess the patient's respiratory rate, rhythm, and effort.
D. Apply a non-rebreather mask at 10 L/min.
Answer: C
Rationale: The nurse should first assess the patient's respiratory status, including rate, rhythm, and
effort, to identify potential causes of desaturation. Increasing oxygen without assessment may mask
underlying issues. Encouraging coughing/deep breathing is beneficial but not the first priority. A
non-rebreather mask is not indicated for COPD patients due to risk of oxygen-induced hypoventilation.
12. A nurse is preparing to administer a blood transfusion to a patient. Which action is most
important to prevent a transfusion reaction?
A. Verify the patient's identity using two identifiers.
B. Check the blood product expiration date.
C. Prime the tubing with 0.9% normal saline.
D. Obtain baseline vital signs within 30 minutes of transfusion.
Answer: A
Rationale: The most critical step in preventing a transfusion reaction is verifying the patient's identity
with two identifiers to ensure the correct blood product is administered to the correct patient. Checking
expiration, priming with saline, and obtaining baseline vitals are important but secondary to proper
identification.
13. A nurse is assessing a patient who has a nasogastric (NG) tube set to low intermittent suction.
Which finding indicates that the tube may be obstructed?
A. The patient reports nausea and abdominal distention.
B. The suction canister contains 100 mL of greenish fluid over 8 hours.
C. The pH of aspirated fluid is 3.
D. The nurse is unable to aspirate gastric contents.
Answer: D
Rationale: Inability to aspirate gastric contents suggests the tube is not patent, possibly due to
obstruction or malposition. Nausea and distention may indicate obstruction but are subjective. A low
output over 8 hours could be normal. A pH of 3 confirms gastric placement but does not assess patency.
14. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving a continuous heparin
infusion. The aPTT result is 120 seconds. What is the nurse's priority action?
A. Increase the heparin infusion rate per protocol.
B. Stop the infusion and notify the healthcare provider.
C. Administer protamine sulfate immediately.
D. Document the result and continue monitoring.
Answer: B
Rationale: An aPTT of 120 seconds is significantly above the therapeutic range (typically 60-80 seconds),
indicating a high risk of bleeding. The nurse should stop the infusion and notify the provider for dose
adjustment. Increasing the rate would worsen the situation. Protamine sulfate is an antidote but should
Page 4
