ATI FUNDAMENTALS CMS 2023 COMPREHENSIVE QUESTIONS AND VERIFIED
ANSWERS (DETAILED & ELABORATED) ACTUAL EXAM TEST/NEWEST UPDATE!!
Question 1
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole
and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of
the following heart sounds should the nurse document?
A) S3 ventricular gallop
B) S4 atrial gallop
C) Pericardial friction rub
D) Midsystolic click
E) Mitral stenosis murmur
Correct Answer: C) Pericardial friction rub
Rationale: A pericardial friction rub is a high-pitched, scratchy, or squeaking sound heard
throughout the cardiac cycle. It is best heard with the diaphragm at the left sternal border
and is indicative of pericardial inflammation, which typically causes pain that intensifies
with deep inspiration or coughing.
Question 2
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
A) Place the bladder of the cuff over the anterior aspect of the thigh.
B) Position the cuff 7.5 cm (3 in) above the popliteal artery.
C) Place the bladder of the cuff over the posterior aspect of the thigh.
D) Use a cuff that is the same size as the one used for the arm.
E) Measure the pressure with the client in a sitting position.
Correct Answer: C) Place the bladder of the cuff over the posterior aspect of the thigh
Rationale: When measuring blood pressure in the lower extremity, the nurse should place
the bladder of the cuff over the posterior aspect of the midthigh. The popliteal artery is the
site for auscultation. Thigh blood pressure is typically higher than arm blood pressure.
Question 3
A charge nurse is teaching adult CPR to a group of new nurses. Which of the following actions
should the charge nurse teach as the first response in CPR?
A) Deliver two rescue breaths.
B) Perform chest compressions.
C) Call for an automated external defibrillator (AED).
D) Confirm unresponsiveness.
E) Check for a carotid pulse.
Correct Answer: D) Confirm unresponsiveness
Rationale: The first step in any emergency situation or CPR sequence is to assess the client
, 2
and the environment. The nurse must confirm the client is unresponsive before activating
the emergency response system or beginning interventions.
Question 4
A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
A) Explain the procedure to the client.
B) Ensure the client is wearing a clean gown.
C) Identify the client using two identifiers.
D) Document the scheduled procedure in the chart.
E) Provide a dose of prescribed pain medication.
Correct Answer: C) Identify the client using two identifiers
Rationale: According to National Patient Safety Goals, the priority action before any
procedure, medication administration, or transport is to verify the client's identity using at
least two identifiers (e.g., name and date of birth) to prevent errors.
Question 5
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A) Encourage the child to cough and clear the throat frequently.
B) Offer red-colored gelatin for a snack.
C) Administer analgesics to the child on a routine schedule.
D) Place the child in a supine position.
E) Provide a straw for drinking clear liquids.
Correct Answer: C) Administer analgesics to the child on a routine schedule throughout the
day and night
Rationale: Effective pain management is crucial for recovery after a tonsillectomy to
encourage fluid intake. Administering pain medication on a routine schedule rather than
PRN (as needed) provides more consistent pain control and prevents the "peaks and
valleys" of discomfort.
Question 6
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the client's
ability to learn new dietary habits?
A) The client’s educational level.
B) The involvement of the client in planning the change.
C) The client's age.
D) The availability of low-sodium food in the local grocery store.
E) The nurse's ability to explain the pathophysiology of heart failure.
Correct Answer: B) The involvement of the client in planning the change
, 3
Rationale: In adult learning, the most significant factor for successful behavioral change is
the client's active participation and motivation. When a client is involved in setting goals
and planning interventions, they are more likely to adhere to the new regimen.
Question 7
A charge nurse is observing a new nurse perform tracheostomy care for a client. Which of the
following actions by the new nurse requires intervention?
A) Using sterile water to rinse the inner cannula.
B) Applying a pre-cut gauze dressing around the stoma.
C) Obtaining cotton balls for the tracheostomy care.
D) Replacing the tracheostomy ties after cleaning.
E) Donning sterile gloves before cleaning the inner cannula.
Correct Answer: C) Obtaining cotton balls for the trach care
Rationale: The nurse should not use cotton balls or any material that can shed fibers (like
cotton-filled gauze) for tracheostomy care. These fibers can be aspirated into the trachea,
causing irritation or infection. Lint-free gauze or applicators should be used instead.
Question 8
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take?
A) Place the client in a Trendelenburg position.
B) Use a thumb and index finger to keep the client's mouth open.
C) Use a stiff-bristled toothbrush to clean the gums.
D) Raise the level of the bed.
E) Perform the procedure alone to maintain privacy.
Correct Answer: D) Raise the level of the bed
Rationale: Raising the bed to a comfortable working height (waist level) is a fundamental
body mechanics principle that prevents provider injury. The client should also be placed in
a side-lying position to prevent aspiration.
Question 9
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following
describes what the nurse is affirming by this action?
A) The client fully understands the risks and benefits of the procedure.
B) The surgeon has answered all of the client's questions.
C) The signature on the preoperative consent form is the client's.
D) The client is making the best possible decision for their health.
E) The nurse has explained the alternative treatments to the client.
Correct Answer: C) The signature on the preop consent form is the client's
Rationale: When a nurse witnesses an informed consent, they are verifying that the
signature is authentic, that the client is competent to sign, and that the client signed it
, 4
voluntarily. The responsibility for ensuring the client understands the procedure rests with
the provider/surgeon.
Question 10
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A) Open the sterile tracheostomy kit.
B) Remove the old tracheostomy dressing.
C) Perform hand hygiene.
D) Don sterile gloves.
E) Suction the tracheostomy tube.
Correct Answer: C) Perform hand hygiene
Rationale: Hand hygiene is always the first step in any clinical procedure to prevent the
transmission of microorganisms and ensure infection control.
Question 11
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the
client's dentures be removed prior to surgery. Which of the following responses should the nurse
make?
A) "It’s hospital policy to remove dentures before surgery."
B) "Don't worry, we will put them in a safe place for you."
C) "What worries you about being without your teeth?"
D) "You can’t wear them because you might swallow them during surgery."
E) "Would you like me to call your family to take them home?"
Correct Answer: C) "What worries you about being without your teeth?"
Rationale: This is a therapeutic communication technique (open-ended question). It allows
the client to express their feelings, fears, or concerns about body image and loss of control,
which helps the nurse address the underlying cause of the agitation.
Question 12
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following assessment statements by the client indicates she is experiencing
psychological distress?
A) "I am feeling more tired than usual after my treatment."
B) "I keep having nightmares about my upcoming surgery."
C) "My appetite has decreased over the last week."
D) "I have a metallic taste in my mouth when I eat."
E) "I am concerned about the cost of my medications."
Correct Answer: B) "I keep having nightmares about my upcoming surgery"
Rationale: Recurring nightmares are a clinical manifestation of psychological distress or
ANSWERS (DETAILED & ELABORATED) ACTUAL EXAM TEST/NEWEST UPDATE!!
Question 1
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole
and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of
the following heart sounds should the nurse document?
A) S3 ventricular gallop
B) S4 atrial gallop
C) Pericardial friction rub
D) Midsystolic click
E) Mitral stenosis murmur
Correct Answer: C) Pericardial friction rub
Rationale: A pericardial friction rub is a high-pitched, scratchy, or squeaking sound heard
throughout the cardiac cycle. It is best heard with the diaphragm at the left sternal border
and is indicative of pericardial inflammation, which typically causes pain that intensifies
with deep inspiration or coughing.
Question 2
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
A) Place the bladder of the cuff over the anterior aspect of the thigh.
B) Position the cuff 7.5 cm (3 in) above the popliteal artery.
C) Place the bladder of the cuff over the posterior aspect of the thigh.
D) Use a cuff that is the same size as the one used for the arm.
E) Measure the pressure with the client in a sitting position.
Correct Answer: C) Place the bladder of the cuff over the posterior aspect of the thigh
Rationale: When measuring blood pressure in the lower extremity, the nurse should place
the bladder of the cuff over the posterior aspect of the midthigh. The popliteal artery is the
site for auscultation. Thigh blood pressure is typically higher than arm blood pressure.
Question 3
A charge nurse is teaching adult CPR to a group of new nurses. Which of the following actions
should the charge nurse teach as the first response in CPR?
A) Deliver two rescue breaths.
B) Perform chest compressions.
C) Call for an automated external defibrillator (AED).
D) Confirm unresponsiveness.
E) Check for a carotid pulse.
Correct Answer: D) Confirm unresponsiveness
Rationale: The first step in any emergency situation or CPR sequence is to assess the client
, 2
and the environment. The nurse must confirm the client is unresponsive before activating
the emergency response system or beginning interventions.
Question 4
A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
A) Explain the procedure to the client.
B) Ensure the client is wearing a clean gown.
C) Identify the client using two identifiers.
D) Document the scheduled procedure in the chart.
E) Provide a dose of prescribed pain medication.
Correct Answer: C) Identify the client using two identifiers
Rationale: According to National Patient Safety Goals, the priority action before any
procedure, medication administration, or transport is to verify the client's identity using at
least two identifiers (e.g., name and date of birth) to prevent errors.
Question 5
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A) Encourage the child to cough and clear the throat frequently.
B) Offer red-colored gelatin for a snack.
C) Administer analgesics to the child on a routine schedule.
D) Place the child in a supine position.
E) Provide a straw for drinking clear liquids.
Correct Answer: C) Administer analgesics to the child on a routine schedule throughout the
day and night
Rationale: Effective pain management is crucial for recovery after a tonsillectomy to
encourage fluid intake. Administering pain medication on a routine schedule rather than
PRN (as needed) provides more consistent pain control and prevents the "peaks and
valleys" of discomfort.
Question 6
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the client's
ability to learn new dietary habits?
A) The client’s educational level.
B) The involvement of the client in planning the change.
C) The client's age.
D) The availability of low-sodium food in the local grocery store.
E) The nurse's ability to explain the pathophysiology of heart failure.
Correct Answer: B) The involvement of the client in planning the change
, 3
Rationale: In adult learning, the most significant factor for successful behavioral change is
the client's active participation and motivation. When a client is involved in setting goals
and planning interventions, they are more likely to adhere to the new regimen.
Question 7
A charge nurse is observing a new nurse perform tracheostomy care for a client. Which of the
following actions by the new nurse requires intervention?
A) Using sterile water to rinse the inner cannula.
B) Applying a pre-cut gauze dressing around the stoma.
C) Obtaining cotton balls for the tracheostomy care.
D) Replacing the tracheostomy ties after cleaning.
E) Donning sterile gloves before cleaning the inner cannula.
Correct Answer: C) Obtaining cotton balls for the trach care
Rationale: The nurse should not use cotton balls or any material that can shed fibers (like
cotton-filled gauze) for tracheostomy care. These fibers can be aspirated into the trachea,
causing irritation or infection. Lint-free gauze or applicators should be used instead.
Question 8
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take?
A) Place the client in a Trendelenburg position.
B) Use a thumb and index finger to keep the client's mouth open.
C) Use a stiff-bristled toothbrush to clean the gums.
D) Raise the level of the bed.
E) Perform the procedure alone to maintain privacy.
Correct Answer: D) Raise the level of the bed
Rationale: Raising the bed to a comfortable working height (waist level) is a fundamental
body mechanics principle that prevents provider injury. The client should also be placed in
a side-lying position to prevent aspiration.
Question 9
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following
describes what the nurse is affirming by this action?
A) The client fully understands the risks and benefits of the procedure.
B) The surgeon has answered all of the client's questions.
C) The signature on the preoperative consent form is the client's.
D) The client is making the best possible decision for their health.
E) The nurse has explained the alternative treatments to the client.
Correct Answer: C) The signature on the preop consent form is the client's
Rationale: When a nurse witnesses an informed consent, they are verifying that the
signature is authentic, that the client is competent to sign, and that the client signed it
, 4
voluntarily. The responsibility for ensuring the client understands the procedure rests with
the provider/surgeon.
Question 10
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A) Open the sterile tracheostomy kit.
B) Remove the old tracheostomy dressing.
C) Perform hand hygiene.
D) Don sterile gloves.
E) Suction the tracheostomy tube.
Correct Answer: C) Perform hand hygiene
Rationale: Hand hygiene is always the first step in any clinical procedure to prevent the
transmission of microorganisms and ensure infection control.
Question 11
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the
client's dentures be removed prior to surgery. Which of the following responses should the nurse
make?
A) "It’s hospital policy to remove dentures before surgery."
B) "Don't worry, we will put them in a safe place for you."
C) "What worries you about being without your teeth?"
D) "You can’t wear them because you might swallow them during surgery."
E) "Would you like me to call your family to take them home?"
Correct Answer: C) "What worries you about being without your teeth?"
Rationale: This is a therapeutic communication technique (open-ended question). It allows
the client to express their feelings, fears, or concerns about body image and loss of control,
which helps the nurse address the underlying cause of the agitation.
Question 12
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following assessment statements by the client indicates she is experiencing
psychological distress?
A) "I am feeling more tired than usual after my treatment."
B) "I keep having nightmares about my upcoming surgery."
C) "My appetite has decreased over the last week."
D) "I have a metallic taste in my mouth when I eat."
E) "I am concerned about the cost of my medications."
Correct Answer: B) "I keep having nightmares about my upcoming surgery"
Rationale: Recurring nightmares are a clinical manifestation of psychological distress or
