ATI Nursing Fundamentals
Midterm Exam
1. A nurse is reinforcing teaching with a client about hand hygiene. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I can use alcohol-based hand rub after using the restroom.”
B. “I should wash my hands with soap and water for at least 10 seconds.”
C. “Hand hygiene is only necessary after direct contact with clients.”
D. “I should use hot water to kill bacteria.”
✅ Answer: A
Rationale: Alcohol-based hand rubs are effective unless hands are visibly soiled or
after contact with spores (e.g., C. difficile).
2. A nurse is preparing to administer medications via a nasogastric tube. Which of
the following actions should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Check the placement of the tube.
C. Administer the medication.
D. Crush the medications together.
✅ Answer: B
Rationale: Always verify tube placement before administering anything to prevent
aspiration.
,3. Which of the following is an example of a nursing diagnosis?
A. Pneumonia
B. Ineffective airway clearance
C. Chest X-ray results showing infiltrates
D. Productive cough with fever
✅ Answer: B
Rationale: Nursing diagnoses describe patient responses to health problems, not the
disease itself.
4. A nurse is reinforcing teaching about the use of incentive spirometry. Which
instruction should the nurse give the client?
A. “Exhale into the device forcefully.”
B. “Inhale slowly and deeply through the mouthpiece.”
C. “Use the device once every 8 hours.”
D. “Cough after using the spirometer only if you feel short of breath.”
✅ Answer: B
Rationale: Incentive spirometry promotes lung expansion by encouraging slow, deep
inhalation.
5. Which of the following actions should a nurse take to maintain a sterile field?
A. Hold sterile objects below waist level.
B. Add sterile items by dropping them onto the field from 12 inches above.
C. Turn to answer the phone while working on the sterile field.
D. Pour solution directly onto sterile gauze while holding the bottle 6 inches above.
✅ Answer: B
,Rationale: Items should be dropped from a safe height (6–12 inches) without
contaminating the field.
6. A nurse is measuring the apical pulse of a client. Where should the nurse place the
stethoscope?
A. Over the right midclavicular line at the second intercostal space
B. At the midclavicular line, fifth intercostal space, left side
C. At the base of the neck, midline
D. Over the sternum
✅ Answer: B
Rationale: The apical pulse is located at the point of maximal impulse (PMI) — fifth
intercostal space, left midclavicular line.
7. Which of the following clients should the nurse identify as being at greatest risk
for falls?
A. A 22-year-old postoperative client
B. A 45-year-old client with asthma
C. A 70-year-old client taking antihypertensive medications
D. A 32-year-old client with a sprained ankle
✅ Answer: C
Rationale: Older adults and those on antihypertensives are at increased risk due to
orthostatic hypotension and balance changes.
8. When providing oral care to an unconscious client, the nurse should:
A. Use hydrogen peroxide solution.
B. Place the client in a supine position.
C. Use a padded tongue blade to open the mouth.
, D. Rinse the mouth with large amounts of water.
✅ Answer: C
Rationale: Prevents injury to the mouth while maintaining airway safety; position
should be side-lying to reduce aspiration risk.
9. A nurse is documenting in a client’s record. Which entry is written correctly?
A. “Client seems upset.”
B. “Client stated, ‘I feel anxious about my surgery.’”
C. “Client appears uncooperative.”
D. “Client will probably not sleep well tonight.”
✅ Answer: B
Rationale: Documentation should be objective and use the client’s exact words.
10. A nurse is reinforcing teaching about the use of a cane. Which instruction is
correct?
A. Hold the cane on the weaker side.
B. Move the cane forward with the weaker leg.
C. Move the stronger leg first when climbing stairs.
D. Keep the cane on the side opposite the injury at all times.
✅ Answer: B
Rationale: The cane and weak leg move forward together for balance and support.
11. Which of the following should the nurse include in fire safety education (RACE
acronym)?
A. Rescue, Alert, Confine, Extinguish
B. Run, Alarm, Contain, Evacuate
Midterm Exam
1. A nurse is reinforcing teaching with a client about hand hygiene. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I can use alcohol-based hand rub after using the restroom.”
B. “I should wash my hands with soap and water for at least 10 seconds.”
C. “Hand hygiene is only necessary after direct contact with clients.”
D. “I should use hot water to kill bacteria.”
✅ Answer: A
Rationale: Alcohol-based hand rubs are effective unless hands are visibly soiled or
after contact with spores (e.g., C. difficile).
2. A nurse is preparing to administer medications via a nasogastric tube. Which of
the following actions should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Check the placement of the tube.
C. Administer the medication.
D. Crush the medications together.
✅ Answer: B
Rationale: Always verify tube placement before administering anything to prevent
aspiration.
,3. Which of the following is an example of a nursing diagnosis?
A. Pneumonia
B. Ineffective airway clearance
C. Chest X-ray results showing infiltrates
D. Productive cough with fever
✅ Answer: B
Rationale: Nursing diagnoses describe patient responses to health problems, not the
disease itself.
4. A nurse is reinforcing teaching about the use of incentive spirometry. Which
instruction should the nurse give the client?
A. “Exhale into the device forcefully.”
B. “Inhale slowly and deeply through the mouthpiece.”
C. “Use the device once every 8 hours.”
D. “Cough after using the spirometer only if you feel short of breath.”
✅ Answer: B
Rationale: Incentive spirometry promotes lung expansion by encouraging slow, deep
inhalation.
5. Which of the following actions should a nurse take to maintain a sterile field?
A. Hold sterile objects below waist level.
B. Add sterile items by dropping them onto the field from 12 inches above.
C. Turn to answer the phone while working on the sterile field.
D. Pour solution directly onto sterile gauze while holding the bottle 6 inches above.
✅ Answer: B
,Rationale: Items should be dropped from a safe height (6–12 inches) without
contaminating the field.
6. A nurse is measuring the apical pulse of a client. Where should the nurse place the
stethoscope?
A. Over the right midclavicular line at the second intercostal space
B. At the midclavicular line, fifth intercostal space, left side
C. At the base of the neck, midline
D. Over the sternum
✅ Answer: B
Rationale: The apical pulse is located at the point of maximal impulse (PMI) — fifth
intercostal space, left midclavicular line.
7. Which of the following clients should the nurse identify as being at greatest risk
for falls?
A. A 22-year-old postoperative client
B. A 45-year-old client with asthma
C. A 70-year-old client taking antihypertensive medications
D. A 32-year-old client with a sprained ankle
✅ Answer: C
Rationale: Older adults and those on antihypertensives are at increased risk due to
orthostatic hypotension and balance changes.
8. When providing oral care to an unconscious client, the nurse should:
A. Use hydrogen peroxide solution.
B. Place the client in a supine position.
C. Use a padded tongue blade to open the mouth.
, D. Rinse the mouth with large amounts of water.
✅ Answer: C
Rationale: Prevents injury to the mouth while maintaining airway safety; position
should be side-lying to reduce aspiration risk.
9. A nurse is documenting in a client’s record. Which entry is written correctly?
A. “Client seems upset.”
B. “Client stated, ‘I feel anxious about my surgery.’”
C. “Client appears uncooperative.”
D. “Client will probably not sleep well tonight.”
✅ Answer: B
Rationale: Documentation should be objective and use the client’s exact words.
10. A nurse is reinforcing teaching about the use of a cane. Which instruction is
correct?
A. Hold the cane on the weaker side.
B. Move the cane forward with the weaker leg.
C. Move the stronger leg first when climbing stairs.
D. Keep the cane on the side opposite the injury at all times.
✅ Answer: B
Rationale: The cane and weak leg move forward together for balance and support.
11. Which of the following should the nurse include in fire safety education (RACE
acronym)?
A. Rescue, Alert, Confine, Extinguish
B. Run, Alarm, Contain, Evacuate
