ATI RN Fundamentals Online Practice Assessment 2019
Version 1– Nursing Foundations Practice Questions and
Rationales
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following food
items should the nurse offer?
A. Orange juice with pulp
B. Fat-free broth
C. Vanilla pudding
D. Plain yogurt
Ans: B
Rationale: A clear liquid diet consists of foods that are liquid at room temperature and are translucent.
Fat-free broth is an appropriate choice because it is transparent and does not leave residue in the
gastrointestinal tract. Orange juice with pulp is considered a full liquid because the pulp provides solids.
Vanilla pudding and plain yogurt are also classified as full liquids due to their dairy content and opacity.
Providing the correct diet helps prevent complications during recovery or before diagnostic tests. The
nurse must verify the diet order before serving any trays to the client. Maintaining nutritional safety is a
core component of fundamental nursing care.
2. A nurse is preparing to administer an intramuscular injection to an adult client. At which of the following
angles should the nurse insert the needle?
A. 90 degrees
B. 45 degrees
C. 15 degrees
,D. 30 degrees
Ans: A
Rationale: Intramuscular injections should be administered at a 90-degree angle to ensure the
medication reaches the muscle tissue. A 15-degree angle is typically used for intradermal injections like
TB skin tests. Subcutaneous injections are generally given at 45 or 90 degrees depending on the amount
of adipose tissue. Using the correct angle reduces the risk of tissue irritation and ensures proper
absorption. The nurse should also select an appropriate site such as the ventrogluteal or deltoid muscle.
Proper technique involves pulling the skin taut or using the Z-track method. Ensuring patient safety
through correct administration technique is essential for effective treatment.
3. A nurse is documenting in a client’s medical record. Which of the following entries is an example of
objective data?
A. Client states, ‘I feel very nauseous.’
B. Client appears to be in a lot of pain.
C. Client’s skin is warm and dry to the touch.
D. Client says they are worried about the surgery.
Ans: C
Rationale: Objective data consists of observable and measurable information obtained through physical
examination and assessment. The description of the client’s skin as warm and dry is a physical finding
that can be verified by others. Statements made by the client, such as feeling nauseous or worried, are
considered subjective data. Subjective data reflects the client’s personal perceptions and feelings which
cannot be directly measured. Using terms like ‘appears to be’ is subjective and should be avoided in
professional documentation. Clear and accurate documentation is necessary for continuity of care and
,legal protection. The nurse must remain factual and avoid including personal biases in the medical
record.
4. A nurse is caring for a client who is on contact precautions. Which of the following actions should the
nurse take?
A. Wear a mask when within 3 feet of the client.
B. Dedicate a disposable stethoscope for the client’s use.
C. Place the client in a room with negative airflow.
D. Keep the door to the client’s room closed at all times.
Ans: B
Rationale: Contact precautions require the use of dedicated or disposable equipment to prevent the
spread of microorganisms. Using a dedicated stethoscope limits the risk of cross-contamination between
patients in the facility. Masks are typically required for droplet precautions rather than standard contact
precautions. Negative airflow rooms are specifically indicated for patients on airborne precautions like
tuberculosis. Keeping the door closed is also a requirement for airborne precautions but not strictly for
contact precautions. Hand hygiene remains the most critical step before and after interacting with the
client environment. The nurse should always wear gloves and a gown when providing direct care.
5. A nurse is teaching a client about using a cane for ambulation. Which of the following instructions should
the nurse include?
A. Hold the cane on the stronger side of the body.
B. Move the stronger leg forward first.
C. Keep the cane 30 cm (12 in) in front of the feet.
D. Hold the cane on the weaker side of the body.
, Ans: A
Rationale: The client should hold the cane on the stronger side of the body to provide maximum support
and balance. This positioning helps shift weight away from the weaker or injured limb during movement.
When walking, the client should move the cane forward first, followed by the weaker leg. The stronger leg
is then moved past the cane to complete the step. Keeping the cane too far in front can lead to instability
and potential falls. Proper cane height should be at the level of the greater trochanter for optimal
ergonomics. Teaching correct mobility techniques is vital for patient safety and independence during
rehabilitation.
6. A nurse is assisting with a sterile dressing change. Which of the following actions violates surgical aseptic
technique?
A. Opening the sterile pack away from the body.
B. Keeping the sterile field above waist level.
C. Reaching over the sterile field to pick up a gauze.
D. Dropping sterile items onto the center of the field.
Ans: C
Rationale: Reaching over a sterile field is a violation of aseptic technique because microorganisms can
fall from the nurse’s sleeves or skin. To maintain sterility, the nurse must always work around the
perimeter of the field. Items must be dropped into the center of the sterile field to avoid touching the 1-
inch non-sterile border. The field must always be kept within the nurse’s line of vision to ensure it has not
been contaminated. Keeping the field above waist level is necessary because anything below the waist is
considered contaminated. Sterile packs should be opened with the first flap away from the body to
prevent reaching over. Constant vigilance is required to prevent healthcare-associated infections during
procedures.
Version 1– Nursing Foundations Practice Questions and
Rationales
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following food
items should the nurse offer?
A. Orange juice with pulp
B. Fat-free broth
C. Vanilla pudding
D. Plain yogurt
Ans: B
Rationale: A clear liquid diet consists of foods that are liquid at room temperature and are translucent.
Fat-free broth is an appropriate choice because it is transparent and does not leave residue in the
gastrointestinal tract. Orange juice with pulp is considered a full liquid because the pulp provides solids.
Vanilla pudding and plain yogurt are also classified as full liquids due to their dairy content and opacity.
Providing the correct diet helps prevent complications during recovery or before diagnostic tests. The
nurse must verify the diet order before serving any trays to the client. Maintaining nutritional safety is a
core component of fundamental nursing care.
2. A nurse is preparing to administer an intramuscular injection to an adult client. At which of the following
angles should the nurse insert the needle?
A. 90 degrees
B. 45 degrees
C. 15 degrees
,D. 30 degrees
Ans: A
Rationale: Intramuscular injections should be administered at a 90-degree angle to ensure the
medication reaches the muscle tissue. A 15-degree angle is typically used for intradermal injections like
TB skin tests. Subcutaneous injections are generally given at 45 or 90 degrees depending on the amount
of adipose tissue. Using the correct angle reduces the risk of tissue irritation and ensures proper
absorption. The nurse should also select an appropriate site such as the ventrogluteal or deltoid muscle.
Proper technique involves pulling the skin taut or using the Z-track method. Ensuring patient safety
through correct administration technique is essential for effective treatment.
3. A nurse is documenting in a client’s medical record. Which of the following entries is an example of
objective data?
A. Client states, ‘I feel very nauseous.’
B. Client appears to be in a lot of pain.
C. Client’s skin is warm and dry to the touch.
D. Client says they are worried about the surgery.
Ans: C
Rationale: Objective data consists of observable and measurable information obtained through physical
examination and assessment. The description of the client’s skin as warm and dry is a physical finding
that can be verified by others. Statements made by the client, such as feeling nauseous or worried, are
considered subjective data. Subjective data reflects the client’s personal perceptions and feelings which
cannot be directly measured. Using terms like ‘appears to be’ is subjective and should be avoided in
professional documentation. Clear and accurate documentation is necessary for continuity of care and
,legal protection. The nurse must remain factual and avoid including personal biases in the medical
record.
4. A nurse is caring for a client who is on contact precautions. Which of the following actions should the
nurse take?
A. Wear a mask when within 3 feet of the client.
B. Dedicate a disposable stethoscope for the client’s use.
C. Place the client in a room with negative airflow.
D. Keep the door to the client’s room closed at all times.
Ans: B
Rationale: Contact precautions require the use of dedicated or disposable equipment to prevent the
spread of microorganisms. Using a dedicated stethoscope limits the risk of cross-contamination between
patients in the facility. Masks are typically required for droplet precautions rather than standard contact
precautions. Negative airflow rooms are specifically indicated for patients on airborne precautions like
tuberculosis. Keeping the door closed is also a requirement for airborne precautions but not strictly for
contact precautions. Hand hygiene remains the most critical step before and after interacting with the
client environment. The nurse should always wear gloves and a gown when providing direct care.
5. A nurse is teaching a client about using a cane for ambulation. Which of the following instructions should
the nurse include?
A. Hold the cane on the stronger side of the body.
B. Move the stronger leg forward first.
C. Keep the cane 30 cm (12 in) in front of the feet.
D. Hold the cane on the weaker side of the body.
, Ans: A
Rationale: The client should hold the cane on the stronger side of the body to provide maximum support
and balance. This positioning helps shift weight away from the weaker or injured limb during movement.
When walking, the client should move the cane forward first, followed by the weaker leg. The stronger leg
is then moved past the cane to complete the step. Keeping the cane too far in front can lead to instability
and potential falls. Proper cane height should be at the level of the greater trochanter for optimal
ergonomics. Teaching correct mobility techniques is vital for patient safety and independence during
rehabilitation.
6. A nurse is assisting with a sterile dressing change. Which of the following actions violates surgical aseptic
technique?
A. Opening the sterile pack away from the body.
B. Keeping the sterile field above waist level.
C. Reaching over the sterile field to pick up a gauze.
D. Dropping sterile items onto the center of the field.
Ans: C
Rationale: Reaching over a sterile field is a violation of aseptic technique because microorganisms can
fall from the nurse’s sleeves or skin. To maintain sterility, the nurse must always work around the
perimeter of the field. Items must be dropped into the center of the sterile field to avoid touching the 1-
inch non-sterile border. The field must always be kept within the nurse’s line of vision to ensure it has not
been contaminated. Keeping the field above waist level is necessary because anything below the waist is
considered contaminated. Sterile packs should be opened with the first flap away from the body to
prevent reaching over. Constant vigilance is required to prevent healthcare-associated infections during
procedures.
