Nursing Study Guide, ATI Fundamentals Practice Questions &
Answers, ATI Fundamentals Exam Prep, ATI Fundamentals
Content Mastery Series, Comprehensive Fundamentals of
Nursing Review, Nursing Foundations, Nursing Process,
Clinical Judgment, Critical Thinking, Prioritization,
Delegation & Assignment, Scope of Practice, Standards of
Nursing Practice, Legal & Ethical Nursing, Patient Safety,
Infection Control, Aseptic Technique, Safety & Emergency
Procedures, Vital Signs, Health Assessment, Communication,
Documentation, Medication Administration, Pain
Management, Mobility & Immobility, Hygiene & Personal
Care, Nutrition, Elimination, Fluid & Electrolytes,
Oxygenation, Wound Care, Perioperative Nursing, Patient
Education, Cultural Considerations, End-of-Life Care, NCLEX-
Style Practice & Detailed Rationales
Question 1: A nurse is preparing to administer a medication to a
client. Which of the following actions is the priority to ensure client
safety?
A. Verify the client's identity using two identifiers
B. Check the medication's expiration date
C. Review the client's allergy history
D. Perform hand hygiene
CORRECT ANSWER: A. Verify the client's identity using two
identifiers
Rationale: While all of these actions are important components of safe
medication administration, verifying the client's identity using two unique
identifiers (such as name and date of birth) is the foundational and priority
step. This action directly prevents the most serious medication error:
administering a medication to the wrong client. According to The Joint
Commission's National Patient Safety Goals, this must be done prior to any
medication administration .
Question 2: A nurse is caring for a client who has an indwelling
urinary catheter and reports a need to urinate. Which of the
following actions should the nurse take?
A. Reassure the client that it is not possible to urinate with a catheter in
place
,B. Check the catheter tubing for kinks or obstruction
C. Collect a urine specimen for analysis immediately
D. Recatheterize the bladder with a larger-gauge catheter
CORRECT ANSWER: B. Check the catheter tubing for kinks or
obstruction
Rationale: The sensation of needing to urinate while an indwelling catheter
is in place often indicates that the catheter is not draining properly. The
most common causes are kinks in the tubing, the drainage bag being
positioned above the level of the bladder, or an obstruction within the
catheter itself. The nurse's first action should be to assess the patency of
the system to identify and correct any simple mechanical issues .
Question 3: A nurse is admitting a client who is malnourished. The
client states, "My wedding ring is loose and I'm worried I will lose
it if it falls off." Which of the following is an appropriate response
by the nurse?
A. "I will place it in your drawer so it won't get lost."
B. "I can pin it to your hospital gown so you won't lose it."
C. "I will hold onto it until a family member can take it home."
D. "I can put it in a locked storage unit for you."
CORRECT ANSWER: D. "I can put it in a locked storage unit for
you."
Rationale: Placing valuables in a locked storage area is the safest and most
secure option to protect the client's belongings and prevent loss or theft.
Placing items in an unlocked drawer or pinning them to a gown creates a
significant risk of loss. The nurse should avoid taking personal possession
of client valuables to prevent any appearance of impropriety and to ensure
proper chain of custody .
Question 4: A nurse is explaining the levels of health care services.
Which of the following settings should the nurse classify as tertiary
care?
A. A community health clinic
B. A hospital's intensive care unit (ICU)
C. A home health agency
D. A rehabilitation center
,CORRECT ANSWER: B. A hospital's intensive care unit (ICU)
Rationale: Tertiary care involves the provision of specialized, highly
technical care for clients with complex or rare conditions. Intensive care
units, oncology treatment centers, and burn centers are classic examples of
tertiary care settings. Community health clinics provide primary care, while
home health agencies and rehabilitation centers primarily provide
restorative or continuing care .
Question 5: A nurse is preparing to perform a sterile procedure.
Which of the following actions maintains sterile technique?
A. The nurse reaches over the sterile field to place an item
B. The nurse holds an item to add to the sterile field at 6 inches above the
field
C. The nurse touches the outer wrapping of a sterile package to open it
D. The nurse turns away from the sterile field to pick up a necessary supply
CORRECT ANSWER: B. The nurse holds an item to add to the
sterile field at 6 inches above the field
Rationale: When adding a sterile item to a sterile field, the item should be
held at least 6 inches above the field to avoid accidental contact with the
field's edges or the nurse's body. Reaching over a sterile field is prohibited
because it contaminates the field. Turning away from a sterile field also
contaminates it because the field is no longer within the range of vision.
The inner, not outer, wrapping of a sterile package is considered sterile .
Question 6: A nurse is caring for a client with diarrhea caused by
Shigella. Which type of precautions should the nurse implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective environment
CORRECT ANSWER: C. Contact precautions
Rationale: Shigella is transmitted via the fecal-oral route through direct
contact with contaminated surfaces or hands. Therefore, Contact
Precautions are required to prevent the transmission of this organism. This
includes wearing gloves and a gown when providing direct care. Airborne
, precautions are for diseases like tuberculosis, and droplet precautions are
for diseases like influenza .
Question 7: A nurse is providing discharge teaching to a client who
has a new prescription for a metered-dose inhaler (MDI). Which of
the following instructions should the nurse include?
A. "Inhale rapidly and deeply when activating the inhaler."
B. "Hold your breath for 10 seconds after inhaling the medication."
C. "Activate the inhaler before you begin to inhale."
D. "Exhale forcefully immediately after inhaling the medication."
CORRECT ANSWER: B. "Hold your breath for 10 seconds after
inhaling the medication."
Rationale: Holding the breath for approximately 10 seconds after inhaling
the medication allows it to deposit deeply in the lungs and maximizes its
therapeutic effect. The client should inhale slowly and deeply, activate the
inhaler during inhalation, and wait before exhaling. Inhaling too rapidly or
activating the inhaler before inhaling can cause the medication to deposit in
the mouth and throat rather than the lungs .
Question 8: A nurse is caring for a client who is NPO and has a
nasogastric (NG) tube. Which of the following findings should
indicate to the nurse that the NG tube is in the correct position?
A. The client is able to speak clearly
B. The pH of the gastric aspirate is 4
C. The tube is taped securely to the client's nose
D. The nurse auscultates a gurgling sound over the epigastric area after
injecting air
CORRECT ANSWER: B. The pH of the gastric aspirate is 4
Rationale: Measuring the pH of gastric aspirate is the most reliable bedside
method for confirming initial NG tube placement. A pH of 4 or less is
strongly indicative of gastric placement. Auscultating for a gurgling sound
(the "whoosh" test) is no longer considered a reliable method for
verification. Secure taping does not confirm internal placement, and a client
may be able to speak even with an NG tube in place .