ATI Fundamentals Exam 2024 NCLEX-Style 100 Questions with Rationales & Cheat Sheets

51. A nurse documents “pitting edema 2+ in lower extremities.” What does this finding indicate? A. Dehydration B. Normal aging C. Fluid volume excess D. Hypothermia Correct Answer: C. Fluid volume excess Rationale: Pitting edema indicates fluid retention and can signal heart failure or renal compromise. ________________________________________52. A nurse is reinforcing teaching for a client prescribed a low-sodium diet. Which food selection is appropriate? A. Canned soup B. Fresh fruits C. Processed cheese D. Deli meats Correct Answer: B. Fresh fruits Rationale: Fresh produce is naturally low in sodium and appropriate for sodium-restricted diets. ________________________________________53. A nurse notes a pressure injury on a client's sacrum. Which nursing diagnosis is most appropriate? A. Impaired gas exchange B. Impaired skin integrity C. Risk for infection D. Acute pain Correct Answer: B. Impaired skin integrity Rationale: Skin breakdown is best reflected by this nursing diagnosis. ________________________________________54. What should the nurse do if a client refuses a scheduled medication? A. Document the refusal and explain to the provider B. Insist the client take the medication C. Discard the medication without documentation D. Double the dose at the next administration Correct Answer: A. Document the refusal and explain to the provider Rationale: Clients have the right to refuse medication. Documentation and communication are essential. ________________________________________55. Which finding is most concerning in a postoperative client? A. Temperature of 99.2°F (37.3°C) B. Blood pressure of 130/84 mmHg C. Respiratory rate of 8 breaths per minute D. Pain rating of 7/10 Correct Answer: C. Respiratory rate of 8 breaths per minute Rationale: A low respiratory rate may indicate oversedation or respiratory depression. ________________________________________56. A nurse reinforces teaching about proper use of a walker. Which client statement shows understanding? A. “I will move my strong leg with the walker.” B. “I should keep the walker behind me while walking.” C. “I should move the walker first, then step forward.” D. “I can place all my weight on the walker.” Correct Answer: C. “I should move the walker first, then step forward.” Rationale: This promotes balance and prevents tripping or falls. ________________________________________57. A nurse applies restraints to a confused client. What action is required? A. Remove restraints every 4 hours B. Document restraint use every 8 hours C. Obtain a provider order within 1 hour D. Tie restraints to the side rail Correct Answer: C. Obtain a provider order within 1 hour Rationale: Restraints require timely medical authorization and frequent monitoring. ________________________________________58. What intervention promotes circulation in a postoperative client? A. Bedrest for 24 hours B. Use of sequential compression devices C. Lowering fluid intake D. Applying cold compresses to the legs Correct Answer: B. Use of sequential compression devices Rationale: SCDs prevent venous stasis and promote circulation in immobile clients. ________________________________________59. Which action best reduces the risk of hospital-acquired infections (HAIs)? A. Wearing gloves at all times B. Taking client temperatures hourly C. Frequent hand hygiene D. Administering prophylactic antibiotics Correct Answer: C. Frequent hand hygiene Rationale: Hand hygiene is the most effective way to prevent the spread of infection. ________________________________________60. A nurse teaches a client to use an incentive spirometer. What instruction is most appropriate? A. “Exhale quickly into the mouthpiece.” B. “Inhale slowly and deeply, then hold for a few seconds.” C. “Blow out forcefully and repeat rapidly.” D. “Use it once per day to strengthen your lungs.” Correct Answer: B. “Inhale slowly and deeply, then hold for a few seconds.” Rationale: Incentive spirometry encourages deep breathing to prevent atelectasis and promote lung expansion.________________________________________66. A nurse is reinforcing teaching about preventing aspiration in a client with dysphagia. Which of the following statements indicate understanding? Select all that apply. A. “I’ll eat while lying in bed.” B. “I’ll tuck my chin when I swallow.” C. “I’ll avoid drinking liquids with meals.” D. “I’ll sit upright during meals.” E. “I’ll take small bites and chew slowly.” Correct Answers: B, D, E Rationale: Chin tuck, upright positioning, and slow, deliberate chewing reduce aspiration risk. Eating while lying down and avoiding liquids unnecessarily increase difficulty swallowing. ________________________________________ 67. Which of the following actions should the nurse take when collecting a stool specimen for occult blood testing? Select all that apply. A. Use a clean specimen container B. Wear gloves during collection C. Apply stool directly from the rectal vault D. Avoid contamination with urine or toilet paper E. Label the specimen and send promptly to lab Correct Answers: A, B, D, E Rationale: Use a clean container, wear gloves, avoid contamination, and promptly label and send the sample. Rectal samples are not necessary unless ordered. ________________________________________ 68. A nurse is reinforcing teaching about sleep hygiene. Which of the following client statements indicate understanding? Select all that apply. A. “I’ll keep a regular bedtime.” B. “I’ll drink coffee before bed to relax.” C. “I’ll avoid naps during the day.” D. “I’ll use my bed only for sleep.” E. “I’ll exercise vigorously right before bedtime.” Correct Answers: A, C, D Rationale: Good sleep hygiene includes consistency, limiting daytime sleep, and reserving the bed for sleep. Caffeine and late exercise disturb sleep