ATI Fundamentals Proctored
Exam 2025–2026 | Verified
Test Bank with Detailed
Rationales
,1. A nurse is assessing a client's peripheral vascular status. Which finding should
the nurse report to the provider immediately?
a) +2 radial pulses bilaterally
b) Capillary refill of 2 seconds
c) Unilateral calf swelling and warmth
d) Mild ankle edema after prolonged standing
Rationale: Unilateral calf swelling and warmth suggest deep vein thrombosis (DVT), a
life-threatening condition that requires immediate intervention to prevent pulmonary
embolism. The other options are expected or non-urgent findings.
2. A client reports difficulty sleeping in the hospital. Which nursing intervention is
most appropriate to promote sleep?
a) Administer a PRN sedative hypnotic as first-line action
b) Keep all lights on to orient the client to time
c) Offer a back massage and reduce environmental noise
d) Encourage the client to watch television until drowsy
Rationale: Non-pharmacological interventions like back massage and noise reduction
promote relaxation and sleep hygiene. Sedatives are not first-line; lights and TV can
disrupt circadian rhythms.
3. A nurse is preparing to insert an indwelling urinary catheter for a female client.
Which technique is correct for maintaining sterility?
a) Clean the meatus with antiseptic solution using a circular motion from the outer to
inner area
b) Use a sterile drape and maintain the catheter tip within the sterile field
c) Lubricate the catheter after opening the sterile package
d) Position the client supine with knees slightly flexed
Rationale: Maintaining the catheter tip within the sterile field prevents contamination.
Cleaning should be inner to outer; lubrication is applied before insertion from sterile
package; dorsal recumbent position is standard.
4. A nurse is caring for a client with a nasogastric (NG) tube set to continuous low suction. Which
assessment finding indicates proper tube placement?
a) Client reports throat discomfort
b) Gastric aspirate with pH of 3
c) Visible air bubbles when syringe is attached
d) Absence of bowel sounds
,5. A client with a terminal illness tells the nurse, "I'm ready to die. Please just let
me go." Which response by the nurse is most therapeutic?
a) "Don't give up; we have new treatments to try."
b) "You shouldn't say that; your family needs you."
c) "It sounds like you're feeling very tired of fighting."
d) "Let me call the chaplain to talk with you."
Rationale: Reflective listening validates the client's feelings without judgment. The other
responses dismiss the client’s emotions or impose the nurse’s values.
6. A nurse is calculating the intake for a client from 0700 to 1900. The client drank
120 mL of coffee, 240 mL of water, and 180 mL of broth. Intravenous fluids
infused at 50 mL/hr. What is the total intake in mL?
a) 540 mL
b) 1140 mL
c) 840 mL
d) 1440 mL
Rationale: Oral intake = 120+240+180 = 540 mL. IV intake = 50 mL × 12 hrs = 600 mL.
Total = 1140 mL.
7. A nurse observes a nursing student removing a client’s peripheral IV. Which
action requires the nurse to intervene?
a) Applying pressure with sterile gauze after removal
b) Holding the catheter parallel to the skin while withdrawing
c) Removing the catheter slowly and reinserting if resistance is met
d) Cleaning the site with alcohol before removal
Rationale: Never reinsert a partially withdrawn IV catheter due to infection risk. Pressure
and parallel withdrawal are correct; cleaning is optional.
8. A client prescribed enoxaparin (Lovenox) asks why the injection is given in the
abdomen. Which response is correct?
a) "Abdominal injections are less painful than other sites."
b) "The abdomen provides the most consistent absorption of the medication."
, c) "It is easier for clients to self-inject in the abdomen."
d) "There are fewer blood vessels in abdominal tissue."
Rationale: Enoxaparin is given subcutaneously in the abdomen for predictable
absorption due to ample adipose tissue and blood flow. Pain and ease are secondary.
9. A nurse is providing discharge teaching to a client with a new colostomy. Which
statement by the client indicates understanding?
a) "I will change the pouch every morning before eating."
b) "I can use regular soap and water to clean the stoma."
c) "I should expect the stoma to be pink and moist."
d) "I will restrict fluids to reduce output."
Rationale: A healthy stoma is pink and moist (like buccal mucosa). Changing when
output is low (not necessarily morning) is ideal; mild soap only; fluids should not be
restricted.
10. A nurse is caring for a postoperative client who reports pain of 8 on a 0–10
scale. Which action should the nurse take first?
a) Administer prescribed morphine sulfate
b) Reposition the client with pillows
c) Assess the location, quality, and characteristics of the pain
d) Notify the provider immediately
Rationale: Assessment is the first step of the nursing process before intervention. After
assessment, administer analgesia; repositioning may help but not first.
11. A nurse is performing a sterile wound irrigation. Which action breaks sterile
technique?
a) Opening the sterile package away from the body
b) Pouring irrigation solution into a sterile basin held at waist level
c) Donning sterile gloves before opening the solution
d) Holding the irrigant syringe 2.5 cm above the wound
Rationale: Sterile items must remain above waist level. Opening away from body,
gloving before handling solution, and proper syringe height are correct.
Exam 2025–2026 | Verified
Test Bank with Detailed
Rationales
,1. A nurse is assessing a client's peripheral vascular status. Which finding should
the nurse report to the provider immediately?
a) +2 radial pulses bilaterally
b) Capillary refill of 2 seconds
c) Unilateral calf swelling and warmth
d) Mild ankle edema after prolonged standing
Rationale: Unilateral calf swelling and warmth suggest deep vein thrombosis (DVT), a
life-threatening condition that requires immediate intervention to prevent pulmonary
embolism. The other options are expected or non-urgent findings.
2. A client reports difficulty sleeping in the hospital. Which nursing intervention is
most appropriate to promote sleep?
a) Administer a PRN sedative hypnotic as first-line action
b) Keep all lights on to orient the client to time
c) Offer a back massage and reduce environmental noise
d) Encourage the client to watch television until drowsy
Rationale: Non-pharmacological interventions like back massage and noise reduction
promote relaxation and sleep hygiene. Sedatives are not first-line; lights and TV can
disrupt circadian rhythms.
3. A nurse is preparing to insert an indwelling urinary catheter for a female client.
Which technique is correct for maintaining sterility?
a) Clean the meatus with antiseptic solution using a circular motion from the outer to
inner area
b) Use a sterile drape and maintain the catheter tip within the sterile field
c) Lubricate the catheter after opening the sterile package
d) Position the client supine with knees slightly flexed
Rationale: Maintaining the catheter tip within the sterile field prevents contamination.
Cleaning should be inner to outer; lubrication is applied before insertion from sterile
package; dorsal recumbent position is standard.
4. A nurse is caring for a client with a nasogastric (NG) tube set to continuous low suction. Which
assessment finding indicates proper tube placement?
a) Client reports throat discomfort
b) Gastric aspirate with pH of 3
c) Visible air bubbles when syringe is attached
d) Absence of bowel sounds
,5. A client with a terminal illness tells the nurse, "I'm ready to die. Please just let
me go." Which response by the nurse is most therapeutic?
a) "Don't give up; we have new treatments to try."
b) "You shouldn't say that; your family needs you."
c) "It sounds like you're feeling very tired of fighting."
d) "Let me call the chaplain to talk with you."
Rationale: Reflective listening validates the client's feelings without judgment. The other
responses dismiss the client’s emotions or impose the nurse’s values.
6. A nurse is calculating the intake for a client from 0700 to 1900. The client drank
120 mL of coffee, 240 mL of water, and 180 mL of broth. Intravenous fluids
infused at 50 mL/hr. What is the total intake in mL?
a) 540 mL
b) 1140 mL
c) 840 mL
d) 1440 mL
Rationale: Oral intake = 120+240+180 = 540 mL. IV intake = 50 mL × 12 hrs = 600 mL.
Total = 1140 mL.
7. A nurse observes a nursing student removing a client’s peripheral IV. Which
action requires the nurse to intervene?
a) Applying pressure with sterile gauze after removal
b) Holding the catheter parallel to the skin while withdrawing
c) Removing the catheter slowly and reinserting if resistance is met
d) Cleaning the site with alcohol before removal
Rationale: Never reinsert a partially withdrawn IV catheter due to infection risk. Pressure
and parallel withdrawal are correct; cleaning is optional.
8. A client prescribed enoxaparin (Lovenox) asks why the injection is given in the
abdomen. Which response is correct?
a) "Abdominal injections are less painful than other sites."
b) "The abdomen provides the most consistent absorption of the medication."
, c) "It is easier for clients to self-inject in the abdomen."
d) "There are fewer blood vessels in abdominal tissue."
Rationale: Enoxaparin is given subcutaneously in the abdomen for predictable
absorption due to ample adipose tissue and blood flow. Pain and ease are secondary.
9. A nurse is providing discharge teaching to a client with a new colostomy. Which
statement by the client indicates understanding?
a) "I will change the pouch every morning before eating."
b) "I can use regular soap and water to clean the stoma."
c) "I should expect the stoma to be pink and moist."
d) "I will restrict fluids to reduce output."
Rationale: A healthy stoma is pink and moist (like buccal mucosa). Changing when
output is low (not necessarily morning) is ideal; mild soap only; fluids should not be
restricted.
10. A nurse is caring for a postoperative client who reports pain of 8 on a 0–10
scale. Which action should the nurse take first?
a) Administer prescribed morphine sulfate
b) Reposition the client with pillows
c) Assess the location, quality, and characteristics of the pain
d) Notify the provider immediately
Rationale: Assessment is the first step of the nursing process before intervention. After
assessment, administer analgesia; repositioning may help but not first.
11. A nurse is performing a sterile wound irrigation. Which action breaks sterile
technique?
a) Opening the sterile package away from the body
b) Pouring irrigation solution into a sterile basin held at waist level
c) Donning sterile gloves before opening the solution
d) Holding the irrigant syringe 2.5 cm above the wound
Rationale: Sterile items must remain above waist level. Opening away from body,
gloving before handling solution, and proper syringe height are correct.
