ATI FUNDAMENTALS OF
NURSING QUESTIONS WITH
ANSWERS AND RATIONALES
1. A nurse is caring for a group of clients. Which of the following clients should the nurse
see first?
A. A client with a new diagnosis of diabetes requiring teaching on insulin administration B. A
client post-op from a hernia repair who has a heart rate of 98/min and blood pressure of 130/80
mm Hg
C. A client who is 1 hour post-op from a thyroidectomy and is reporting stridor D. A
client with chronic kidney disease whose weight has increased by 1 kg since yesterday
Answer: C. A client who is 1 hour post-op from a thyroidectomy and is reporting stridor
Rationale: Stridor is a high-pitched, crowing sound that indicates airway obstruction, a life-
threatening emergency. This client must be seen immediately.
2. A nurse is caring for a client who has a new tracheostomy. Which of the following
findings requires immediate intervention?
A. The client is able to speak
B. Small amount of bloody drainage on the dressing
C. The client's oxygen saturation is 95%
D. The tracheostomy ties have a one-finger gap
Answer: A. The client is able to speak
Page 1 of 39
,Rationale: A client with a new, uncuffed tracheostomy tube should not be able to speak because
air is not passing over the vocal cords. Ability to speak may indicate the cuff is deflated or the
tube is displaced, which is a medical emergency.
3. A nurse is assessing four clients. Which of the following findings is the priority?
A. A client who has a urinary tract infection and reports pelvic pressure
B. A client who has a blood glucose level of 95 mg/dL
C. A client who has a serum potassium level of 6.2 mEq/L
D. A client who has a magnesium level of 1.8 mg/dL
Answer: C. A client who has a serum potassium level of 6.2 mEq/L
*Rationale: A potassium level of 6.2 mEq/L is critically high (hyperkalemia) and can lead to life-
threatening cardiac dysrhythmias. This requires immediate intervention. The other values are
within or near normal limits.*
4. A nurse working on a medical-surgical unit is prioritizing care for four clients.
Which client should the nurse plan to see first?
A. A client who needs a scheduled antibiotic
B. A client who is post-op and has pain of 4 on a 0-10 scale
C. A client who needs discharge teaching
D. A client who just returned from the PACU following a bowel resection
Answer: D. A client who just returned from the PACU following a bowel resection Rationale: A
client returning from the Post-Anesthesia Care Unit (PACU) requires an immediate
comprehensive assessment to establish a new baseline and ensure stability post-operatively and
post-anesthesia.
5. A nurse is caring for a client who is post-operative following a hip replacement. Which of
the following actions should the nurse take first?
A. Administer pain medication as ordered
Page 2 of 39
,B. Assess the client's vital signs
C. Check the neurovascular status of the affected leg
D. Reinforce the surgical dressing
Answer: B. Assess the client's vital signs
Rationale: Using the nursing process, the first step is always assessment. While checking
neurovascular status and pain are important, the nurse must first get an overall picture of the
client's physiological stability by assessing their airway, breathing, and circulation (vital signs).
6. A nurse is caring for a client who has a surgical wound that separates, with viscera
protruding. Which interventions should the nurse perform? (Select all that apply)
A. Cover the area with saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abdomen
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the patient supine with hips and knees bent
E. Offer the patient a warm beverage, such as herbal tea
Answers: A, D
Rationale: Moist sterile dressings (A) prevent the exposed organs from drying out. Flexing the
hips and knees (D) reduces abdominal muscle tension and pressure on the wound. Pressure and
compression are contraindicated, and offering tea is not an appropriate intervention for this
emergency .
7. A nurse is assigning tasks to an LPN. Which task should the LPN question?
A. Assisting a post-op patient to use an incentive spirometer
B. Collecting a clean-catch urine specimen
C. Providing nasopharyngeal suctioning for a stable patient
D. Replacing the cartridge and tubing on a PCA pump
Answer: D. Replacing the cartridge and tubing on a PCA pump
Page 3 of 39
, Rationale: Replacing PCA pump cartridges is a high-risk intervention that requires the critical
thinking and responsibility of an RN. The other tasks fall within the LPN's scope of practice .
8. A charge nurse is determining tasks to assign to assistive personnel (AP). Which task is
appropriate to delegate?
A. Feeding a patient admitted 24 hours ago with aspiration pneumonia
B. Reinforcing cane-walking technique with a patient
C. Reapplying a condom catheter for a patient with urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer: C. Reapplying a condom catheter for a patient with urinary incontinence Rationale:
Application of a condom catheter is a noninvasive and routine task suitable for AP. The other
options require clinical judgment, patient teaching, or sterile technique .
9. An RN is delegating the ambulation of a patient 5 days post-knee arthroplasty to an AP.
What information should the RN include? (Select all that apply)
A. The roommate is up independently
B. The patient ambulates with slippers over antiembolic stockings
C. The patient uses a front-wheeled walker
D. The patient received pain medication 30 minutes ago
E. The patient is allergic to codeine
F. The patient ate 50% of his breakfast
Answers: B, C, D
Rationale: Safety details regarding proper footwear (B), mobility aids (C), and pain control (D)
are essential for safe ambulation. The other information is irrelevant to the task of ambulating
the patient .
10. Can an RN delegate tracheostomy care to an LPN for a patient with pneumonia?
A. Yes
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NURSING QUESTIONS WITH
ANSWERS AND RATIONALES
1. A nurse is caring for a group of clients. Which of the following clients should the nurse
see first?
A. A client with a new diagnosis of diabetes requiring teaching on insulin administration B. A
client post-op from a hernia repair who has a heart rate of 98/min and blood pressure of 130/80
mm Hg
C. A client who is 1 hour post-op from a thyroidectomy and is reporting stridor D. A
client with chronic kidney disease whose weight has increased by 1 kg since yesterday
Answer: C. A client who is 1 hour post-op from a thyroidectomy and is reporting stridor
Rationale: Stridor is a high-pitched, crowing sound that indicates airway obstruction, a life-
threatening emergency. This client must be seen immediately.
2. A nurse is caring for a client who has a new tracheostomy. Which of the following
findings requires immediate intervention?
A. The client is able to speak
B. Small amount of bloody drainage on the dressing
C. The client's oxygen saturation is 95%
D. The tracheostomy ties have a one-finger gap
Answer: A. The client is able to speak
Page 1 of 39
,Rationale: A client with a new, uncuffed tracheostomy tube should not be able to speak because
air is not passing over the vocal cords. Ability to speak may indicate the cuff is deflated or the
tube is displaced, which is a medical emergency.
3. A nurse is assessing four clients. Which of the following findings is the priority?
A. A client who has a urinary tract infection and reports pelvic pressure
B. A client who has a blood glucose level of 95 mg/dL
C. A client who has a serum potassium level of 6.2 mEq/L
D. A client who has a magnesium level of 1.8 mg/dL
Answer: C. A client who has a serum potassium level of 6.2 mEq/L
*Rationale: A potassium level of 6.2 mEq/L is critically high (hyperkalemia) and can lead to life-
threatening cardiac dysrhythmias. This requires immediate intervention. The other values are
within or near normal limits.*
4. A nurse working on a medical-surgical unit is prioritizing care for four clients.
Which client should the nurse plan to see first?
A. A client who needs a scheduled antibiotic
B. A client who is post-op and has pain of 4 on a 0-10 scale
C. A client who needs discharge teaching
D. A client who just returned from the PACU following a bowel resection
Answer: D. A client who just returned from the PACU following a bowel resection Rationale: A
client returning from the Post-Anesthesia Care Unit (PACU) requires an immediate
comprehensive assessment to establish a new baseline and ensure stability post-operatively and
post-anesthesia.
5. A nurse is caring for a client who is post-operative following a hip replacement. Which of
the following actions should the nurse take first?
A. Administer pain medication as ordered
Page 2 of 39
,B. Assess the client's vital signs
C. Check the neurovascular status of the affected leg
D. Reinforce the surgical dressing
Answer: B. Assess the client's vital signs
Rationale: Using the nursing process, the first step is always assessment. While checking
neurovascular status and pain are important, the nurse must first get an overall picture of the
client's physiological stability by assessing their airway, breathing, and circulation (vital signs).
6. A nurse is caring for a client who has a surgical wound that separates, with viscera
protruding. Which interventions should the nurse perform? (Select all that apply)
A. Cover the area with saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abdomen
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the patient supine with hips and knees bent
E. Offer the patient a warm beverage, such as herbal tea
Answers: A, D
Rationale: Moist sterile dressings (A) prevent the exposed organs from drying out. Flexing the
hips and knees (D) reduces abdominal muscle tension and pressure on the wound. Pressure and
compression are contraindicated, and offering tea is not an appropriate intervention for this
emergency .
7. A nurse is assigning tasks to an LPN. Which task should the LPN question?
A. Assisting a post-op patient to use an incentive spirometer
B. Collecting a clean-catch urine specimen
C. Providing nasopharyngeal suctioning for a stable patient
D. Replacing the cartridge and tubing on a PCA pump
Answer: D. Replacing the cartridge and tubing on a PCA pump
Page 3 of 39
, Rationale: Replacing PCA pump cartridges is a high-risk intervention that requires the critical
thinking and responsibility of an RN. The other tasks fall within the LPN's scope of practice .
8. A charge nurse is determining tasks to assign to assistive personnel (AP). Which task is
appropriate to delegate?
A. Feeding a patient admitted 24 hours ago with aspiration pneumonia
B. Reinforcing cane-walking technique with a patient
C. Reapplying a condom catheter for a patient with urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer: C. Reapplying a condom catheter for a patient with urinary incontinence Rationale:
Application of a condom catheter is a noninvasive and routine task suitable for AP. The other
options require clinical judgment, patient teaching, or sterile technique .
9. An RN is delegating the ambulation of a patient 5 days post-knee arthroplasty to an AP.
What information should the RN include? (Select all that apply)
A. The roommate is up independently
B. The patient ambulates with slippers over antiembolic stockings
C. The patient uses a front-wheeled walker
D. The patient received pain medication 30 minutes ago
E. The patient is allergic to codeine
F. The patient ate 50% of his breakfast
Answers: B, C, D
Rationale: Safety details regarding proper footwear (B), mobility aids (C), and pain control (D)
are essential for safe ambulation. The other information is irrelevant to the task of ambulating
the patient .
10. Can an RN delegate tracheostomy care to an LPN for a patient with pneumonia?
A. Yes
Page 4 of 39
