ATI FundAmenTAls Cms ComprehensIve sTudy GuIde
2025–2026 | ATI FundAmenTAls ConTenT mAsTery
serIes (Cms) exAm QuesTIons wITh verIFIed
Answers And deTAIled rATIonAles | ATI rn
FundAmenTAls nursInG prACTICe TesT, revIew
noTes, exAm prepArATIon GuIde For nursInG
sTudenTs And nClex suCCess
Question 1: A nurse is preparing to administer medications to a client. Which action should
the nurse take first to ensure client safety?
A. Verify the client's identity using two identifiers
B. Check the medication against the medication administration record (MAR)
C. Assess the client's allergy status
D. Explain the purpose of each medication to the client
CORRECT ANSWER: A. Verify the client's identity using two identifiers
RATIONALE: The first priority in medication administration is confirming the client's identity
using two unique identifiers (e.g., name and date of birth) to prevent administering medications
to the wrong client. This aligns with the National Patient Safety Goals and is foundational to the
"right patient" principle of the six rights of medication administration.
Question 2: When performing hand hygiene, which situation requires the use of soap and
water rather than an alcohol-based hand rub?
A. After touching a client's intact skin
B. Before inserting an indwelling urinary catheter
C. After caring for a client with Clostridioides difficile infection
D. Before preparing a sterile field
CORRECT ANSWER: C. After caring for a client with Clostridioides difficile infection
RATIONALE: Soap and water are required when hands are visibly soiled or after caring for clients
with spore-forming organisms like Clostridioides difficile, as alcohol-based hand rubs are not
effective against bacterial spores. For all other situations, alcohol-based hand rubs are preferred
due to superior efficacy and skin tolerance.
Question 3: A nurse is assessing a client's pain using the PQRST mnemonic. Which question
corresponds to the "R" component?
,A. "What makes the pain better or worse?"
B. "Where is the pain located?"
C. "How would you describe the pain?"
D. "On a scale of 0 to 10, how intense is the pain?"
CORRECT ANSWER: A. "What makes the pain better or worse?"
RATIONALE: In the PQRST pain assessment mnemonic, "R" stands for "Radiation/Relief," which
includes factors that alleviate or exacerbate the pain. Understanding these triggers helps guide
appropriate interventions and evaluate treatment effectiveness.
Question 4: Which action by a nurse demonstrates adherence to the ethical principle of
autonomy?
A. Administering pain medication before a painful procedure
B. Providing a client with all treatment options and supporting their decision
C. Reporting suspected abuse to the appropriate authorities
D. Ensuring a client's belongings are secured during hospitalization
CORRECT ANSWER: B. Providing a client with all treatment options and supporting their
decision
RATIONALE: Autonomy respects a client's right to make informed decisions about their care.
Providing comprehensive information and supporting the client's choice, even if it differs from
the nurse's recommendation, upholds this fundamental ethical principle.
Question 5: A nurse is teaching a client about fall prevention at home. Which
recommendation is most appropriate?
A. "Keep throw rugs on hardwood floors for comfort."
B. "Install grab bars in the shower and near the toilet."
C. "Use a step stool to reach items on high shelves."
D. "Walk in socks rather than shoes indoors for better traction."
CORRECT ANSWER: B. "Install grab bars in the shower and near the toilet."
RATIONALE: Grab bars provide stability in high-risk areas like bathrooms, significantly reducing
fall risk. Throw rugs, step stools, and walking in socks increase fall hazards and should be
avoided in fall prevention education.
Question 6: When documenting in a client's medical record, which practice is considered
legally defensible?
,A. Using abbreviations approved by the facility
B. Charting care immediately after it is provided
C. Correcting errors by drawing a single line through the mistake and initialing
D. All of the above
CORRECT ANSWER: D. All of the above
RATIONALE: Legally defensible documentation includes using only facility-approved
abbreviations, charting contemporaneously to ensure accuracy, and correcting errors properly
without obscuring the original entry. These practices maintain record integrity and support
continuity of care.
Question 7: A nurse is preparing to transfer a client from bed to chair. Which action should the
nurse take to protect both the client and self from injury?
A. Ask the client to hold onto the nurse's neck for stability
B. Use a gait belt and maintain a wide base of support
C. Lift the client quickly to minimize discomfort
D. Allow the client to lead the transfer without assistance
CORRECT ANSWER: B. Use a gait belt and maintain a wide base of support
RATIONALE: Using a gait belt provides a secure hold for the client while allowing the nurse to
maintain proper body mechanics. A wide base of support enhances stability, reducing the risk of
musculoskeletal injury to the nurse and falls for the client.
Question 8: Which finding indicates that a client is experiencing hypoxia?
A. Warm, dry skin
B. Restlessness and confusion
C. Bradycardia
D. Decreased respiratory rate
CORRECT ANSWER: B. Restlessness and confusion
RATIONALE: Restlessness and confusion are early neurological signs of hypoxia due to
decreased oxygen delivery to the brain. Other signs include tachycardia, tachypnea, and
cyanosis. Warm skin, bradycardia, and decreased respiratory rate are not typical indicators of
hypoxia.
Question 9: A nurse is caring for a client with a stage II pressure injury. Which intervention is
priority?
, A. Apply a dry gauze dressing
B. Reposition the client every 2 hours
C. Massage the area around the injury
D. Use a donut-shaped cushion for seating
CORRECT ANSWER: B. Reposition the client every 2 hours
RATIONALE: Frequent repositioning relieves pressure on vulnerable areas, promoting healing
and preventing further tissue damage. Massage can cause shear injury, dry gauze may adhere to
the wound, and donut cushions increase pressure on surrounding tissue.
Question 10: When administering an intramuscular injection, which site is preferred for an
adult client?
A. Deltoid
B. Ventrogluteal
C. Vastus lateralis
D. Dorsogluteal
CORRECT ANSWER: B. Ventrogluteal
RATIONALE: The ventrogluteal site is preferred for IM injections in adults due to its large muscle
mass, absence of major nerves and blood vessels, and consistent absorption. The dorsogluteal
site risks sciatic nerve injury, while deltoid and vastus lateralis are suitable for smaller volumes.
Question 11: A nurse is assessing a client's IV site and notes redness, warmth, and a palpable
cord along the vein. Which complication should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
CORRECT ANSWER: B. Phlebitis
RATIONALE: Phlebitis presents with redness, warmth, pain, and a palpable cord along the vein
due to inflammation. Infiltration involves non-vesicant fluid leaking into surrounding tissue,
causing swelling and coolness. Extravasation involves vesicant medications causing tissue
damage.
Question 12: Which action by a nurse best demonstrates therapeutic communication?
A. Offering personal advice based on experience
B. Using open-ended questions to encourage expression
2025–2026 | ATI FundAmenTAls ConTenT mAsTery
serIes (Cms) exAm QuesTIons wITh verIFIed
Answers And deTAIled rATIonAles | ATI rn
FundAmenTAls nursInG prACTICe TesT, revIew
noTes, exAm prepArATIon GuIde For nursInG
sTudenTs And nClex suCCess
Question 1: A nurse is preparing to administer medications to a client. Which action should
the nurse take first to ensure client safety?
A. Verify the client's identity using two identifiers
B. Check the medication against the medication administration record (MAR)
C. Assess the client's allergy status
D. Explain the purpose of each medication to the client
CORRECT ANSWER: A. Verify the client's identity using two identifiers
RATIONALE: The first priority in medication administration is confirming the client's identity
using two unique identifiers (e.g., name and date of birth) to prevent administering medications
to the wrong client. This aligns with the National Patient Safety Goals and is foundational to the
"right patient" principle of the six rights of medication administration.
Question 2: When performing hand hygiene, which situation requires the use of soap and
water rather than an alcohol-based hand rub?
A. After touching a client's intact skin
B. Before inserting an indwelling urinary catheter
C. After caring for a client with Clostridioides difficile infection
D. Before preparing a sterile field
CORRECT ANSWER: C. After caring for a client with Clostridioides difficile infection
RATIONALE: Soap and water are required when hands are visibly soiled or after caring for clients
with spore-forming organisms like Clostridioides difficile, as alcohol-based hand rubs are not
effective against bacterial spores. For all other situations, alcohol-based hand rubs are preferred
due to superior efficacy and skin tolerance.
Question 3: A nurse is assessing a client's pain using the PQRST mnemonic. Which question
corresponds to the "R" component?
,A. "What makes the pain better or worse?"
B. "Where is the pain located?"
C. "How would you describe the pain?"
D. "On a scale of 0 to 10, how intense is the pain?"
CORRECT ANSWER: A. "What makes the pain better or worse?"
RATIONALE: In the PQRST pain assessment mnemonic, "R" stands for "Radiation/Relief," which
includes factors that alleviate or exacerbate the pain. Understanding these triggers helps guide
appropriate interventions and evaluate treatment effectiveness.
Question 4: Which action by a nurse demonstrates adherence to the ethical principle of
autonomy?
A. Administering pain medication before a painful procedure
B. Providing a client with all treatment options and supporting their decision
C. Reporting suspected abuse to the appropriate authorities
D. Ensuring a client's belongings are secured during hospitalization
CORRECT ANSWER: B. Providing a client with all treatment options and supporting their
decision
RATIONALE: Autonomy respects a client's right to make informed decisions about their care.
Providing comprehensive information and supporting the client's choice, even if it differs from
the nurse's recommendation, upholds this fundamental ethical principle.
Question 5: A nurse is teaching a client about fall prevention at home. Which
recommendation is most appropriate?
A. "Keep throw rugs on hardwood floors for comfort."
B. "Install grab bars in the shower and near the toilet."
C. "Use a step stool to reach items on high shelves."
D. "Walk in socks rather than shoes indoors for better traction."
CORRECT ANSWER: B. "Install grab bars in the shower and near the toilet."
RATIONALE: Grab bars provide stability in high-risk areas like bathrooms, significantly reducing
fall risk. Throw rugs, step stools, and walking in socks increase fall hazards and should be
avoided in fall prevention education.
Question 6: When documenting in a client's medical record, which practice is considered
legally defensible?
,A. Using abbreviations approved by the facility
B. Charting care immediately after it is provided
C. Correcting errors by drawing a single line through the mistake and initialing
D. All of the above
CORRECT ANSWER: D. All of the above
RATIONALE: Legally defensible documentation includes using only facility-approved
abbreviations, charting contemporaneously to ensure accuracy, and correcting errors properly
without obscuring the original entry. These practices maintain record integrity and support
continuity of care.
Question 7: A nurse is preparing to transfer a client from bed to chair. Which action should the
nurse take to protect both the client and self from injury?
A. Ask the client to hold onto the nurse's neck for stability
B. Use a gait belt and maintain a wide base of support
C. Lift the client quickly to minimize discomfort
D. Allow the client to lead the transfer without assistance
CORRECT ANSWER: B. Use a gait belt and maintain a wide base of support
RATIONALE: Using a gait belt provides a secure hold for the client while allowing the nurse to
maintain proper body mechanics. A wide base of support enhances stability, reducing the risk of
musculoskeletal injury to the nurse and falls for the client.
Question 8: Which finding indicates that a client is experiencing hypoxia?
A. Warm, dry skin
B. Restlessness and confusion
C. Bradycardia
D. Decreased respiratory rate
CORRECT ANSWER: B. Restlessness and confusion
RATIONALE: Restlessness and confusion are early neurological signs of hypoxia due to
decreased oxygen delivery to the brain. Other signs include tachycardia, tachypnea, and
cyanosis. Warm skin, bradycardia, and decreased respiratory rate are not typical indicators of
hypoxia.
Question 9: A nurse is caring for a client with a stage II pressure injury. Which intervention is
priority?
, A. Apply a dry gauze dressing
B. Reposition the client every 2 hours
C. Massage the area around the injury
D. Use a donut-shaped cushion for seating
CORRECT ANSWER: B. Reposition the client every 2 hours
RATIONALE: Frequent repositioning relieves pressure on vulnerable areas, promoting healing
and preventing further tissue damage. Massage can cause shear injury, dry gauze may adhere to
the wound, and donut cushions increase pressure on surrounding tissue.
Question 10: When administering an intramuscular injection, which site is preferred for an
adult client?
A. Deltoid
B. Ventrogluteal
C. Vastus lateralis
D. Dorsogluteal
CORRECT ANSWER: B. Ventrogluteal
RATIONALE: The ventrogluteal site is preferred for IM injections in adults due to its large muscle
mass, absence of major nerves and blood vessels, and consistent absorption. The dorsogluteal
site risks sciatic nerve injury, while deltoid and vastus lateralis are suitable for smaller volumes.
Question 11: A nurse is assessing a client's IV site and notes redness, warmth, and a palpable
cord along the vein. Which complication should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
CORRECT ANSWER: B. Phlebitis
RATIONALE: Phlebitis presents with redness, warmth, pain, and a palpable cord along the vein
due to inflammation. Infiltration involves non-vesicant fluid leaking into surrounding tissue,
causing swelling and coolness. Extravasation involves vesicant medications causing tissue
damage.
Question 12: Which action by a nurse best demonstrates therapeutic communication?
A. Offering personal advice based on experience
B. Using open-ended questions to encourage expression
