ATI RN Fundamentals Proctored Practice Exam

Getting ready for the RN Fundamentals ATI proctored exam can feel overwhelming—lots of content, limited time, and zero room for guesswork. That’s exactly why we built this ATI Fundamentals Proctored Exam Practice Questions pack: a clean, exam-style study set you can use today to tighten up weak spots and walk into test day confident. Inside, you’ll find carefully written scenarios, clear distractors, and detailed, plain-English explanations that tell you why the correct answer is right and why the others are not. If you’ve been searching for ati fundamentals proctored exam answers that actually teach (not just list letters), this is it. Download once, study anywhere, and revisit as often as you need. Whether you have two weeks or two days, this practice set helps you identify patterns, master safety-first thinking, and turn knowledge into points. If you want an efficient path from content overload to exam clarity, buy the practice test and start improving in your very next study session.

What you’ll learn from this ATI Proctored Exam Fundamentals Questions

This pack mirrors the way ATI evaluates nursing judgment. We focus on the practical, day-to-day decisions nurses make—prioritizing care, protecting patients, and using core skills safely and effectively. The questions and explanations are mapped to the most repeatedly tested fundamentals themes:

• Safety & prioritization: ABCs, unstable vs. stable, “time-sensitive” red flags (stroke symptoms, meningitis triad, acute respiratory depression), triage logic, SBAR communication, and incident reporting/near-miss culture.
• Infection control & isolation: When to use standard, contact, droplet, and airborne precautions (C. diff, RSV, measles, TB, disseminated varicella), correct PPE donning/doffing sequences, soap-and-water vs. alcohol gel, and transport protocols.
• Medication basics: High-alert meds (insulin, heparin, potassium, opioids), independent double-checks, smart-pump use, rate limits (KCl peripherally), PCA safety, documentation after PRN opioids/benzodiazepines, and infusion reactions (red-man vs. anaphylaxis).
• Calculations & skills: Dose/volume math, blood transfusion safety (two-person check, NS only, first 15 minutes), trach and suction technique, sterile field rules, central-line dressing change bundles, wound irrigation pressure, moist wound healing.
• Chronic care anchors: COPD oxygen targets and pursed-lip breathing coaching, heart-failure self-management (2 g sodium, daily weights, edema red flags), diabetes care (insulin timing, mixing clear before cloudy, foot care, hypoglycemia 15–15 rule), warfarin dietary consistency.
• Devices & mobility: Cane/walker/crutch sequencing on level ground and stairs (“up with the good, down with the bad”), PEG/NG feeding tolerance, chest-tube water-seal interpretation (continuous bubbling = air leak), TPN line infection vigilance.
• Fluid & electrolytes: Hyponatremia safety (seizure precautions, cautious 3% saline), hyperkalemia protection (calcium gluconate), hypokalemia risks with loops/NG suction, hypotonic vs. isotonic fluid choices, and careful sodium correction targets.
• Legal & ethical foundations: Informed consent roles, advance directives (proxy vs. living will), HIPAA do’s and don’ts, therapeutic communication (open-ended, non-judgmental), restraint alternatives and least-restrictive first.
• Health promotion & prevention: Primary vs. secondary vs. tertiary prevention, vaccine/screening examples, community teaching that’s actually testable.

The result? You don’t just memorize; you recognize test logic, apply nursing priorities, and move faster through trickier stems.

Who can take this ATI Fundamentals Practice exam?

• Pre-licensure nursing students in Fundamentals or Med-Surg I who are preparing for the rn fundamentals ati proctored exam and want exam-matching items with explanations that make sense the first time.
• Students repeating ATI who need targeted practice and clearer rationales to convert partial understanding into correct, repeatable decisions.
• Fast-track learners who prefer high-yield questions and scenario-based learning over long, passive reading.

If you’re on a tight timeline, this pack was designed to deliver maximum value per minute: sort your weak areas quickly, drill them, and retest to confirm mastery.

Who is it useful for?

• Visual and scenario learners who learn best when they can see how a concept shows up at the bedside (e.g., “Is that continuous water-seal bubbling normal?”).
• Checklist-style planners who like structured domains: safety, infection control, skills, pharm, F&E, mobility, and teaching.
• Students who want confidence in unfamiliar test wording—our rationales explain test writers’ patterns and common pitfalls so you stop second-guessing.

How many questions are on the ATI Fundamentals Proctored Exam?

ATI can update formats, but the Fundamentals proctored exam typically runs around 60–70 scored questions, plus potential pilot items that don’t count toward your score. Expect a mix of single-best-answer, select-all-that-apply, and practical scenario stems that test safety, prioritization, and foundational nursing care. Your performance is benchmarked across content areas—exactly why practicing across topics matters.

Why these ATI Fundamentals Proctored Exam Practice Questions work

• Exam-style stems: Focused on bedside decisions with plausible distractors—no fluff.
• Teaching rationales: Not just “B is correct.” You get why B works and why A/C/D don’t, so you can answer similar items you’ve never seen before.
• Reinforcement loops: Repeating themes (e.g., CLABSI bundle, PPE order, PCA oversedation steps) appear across contexts to hard-wire safe, test-ready habits.
• Evergreen content: Fundamentals doesn’t age quickly. We emphasize durable, standards-aligned concepts that remain relevant across cohorts.

You’ll naturally encounter and use the keywords you’re searching for—ati fundamentals proctored exam answers, ati fundamentals proctored exam practice questions, and rn fundamentals ati proctored exam—but framed as learning tools, not shortcuts.

Tips for ATI Proctored Exams (How to Pass)

1. Lead with safety. When two answers seem right, choose the option that best protects life, airway, or prevents immediate harm. ABCs, unstable first, and “time-sensitive” conditions win.
2. Match isolation to transmission. C. diff = soap and water + contact; measles/TB/disseminated varicella = airborne + N95; influenza/meningococcal = droplet. Wrong PPE is an instant miss.
3. Know your high-alert rules. No IV push KCl. Peripheral KCl ≤10 mEq/hr via pump. Independent double-checks for IV insulin/heparin. PCA oversedation = stop opioid, stimulate, oxygen, naloxone PRN.
4. Sterile is sterile. Keep the field above the waist and in view; don’t reach over it; allow CHG to dry fully; scrub the hub every access. If you doubt sterility—restart.
5. Fluids & electrolytes are pattern-rich. Hyperkalemia + peaked T waves: stabilize with IV calcium, then shift/remove K⁺. Severe hyponatremia: slow, controlled correction with neuro checks.
6. Mobility sequencing saves points. Cane on strong side; cane + weak leg → strong leg. Walker forward → weaker leg → strong leg. Stairs: “up with the good, down with the bad.”
7. Document like a pro. After PRN meds, chart dose/route/time, indication, objective response at expected onset, and safety data (RR, sedation). Avoid judgment words.
8. Don’t overthink nutrition. Warfarin = consistent vitamin K. Heart failure = 2 g sodium and daily weights with specific red-flag thresholds. Diabetes = rotate within one site and use the 15–15 rule safely.
9. Memorize transfusion safety. Two-person ID check at bedside, NS only, start slow, stay for first 15 minutes, and stop immediately for reaction signs.
10. Practice under time. Do sets of 10–20 items, review rationales, then redo missed domains the next day. You’ll see your pace and accuracy lift together.

What’s inside the pack

• Hundreds of exam-style items built around the exact fundamentals that keep appearing: isolation/PPE, medication safety, blood products, oxygenation, F&E, mobility, delegation, documentation, and patient teaching.
• Layered rationales that teach clinical reasoning, not trivia.
• Clean, printable layout so you can annotate, star tricky stems, and build a quick-review stack the week of your test.
• Goal-based study plan: Use 20-minute sprints (two to three times daily). Do a mixed set, immediately read rationales, then log the themes you missed. Repeat tomorrow focusing only on those themes.

How to use this resource for maximum score lift

1. Baseline check: Do 15 mixed questions cold to find your weak domains.
2. Targeted drill: Spend 30–45 minutes on just those domains (e.g., isolation + high-alert meds).
3. Teach-back: Explain a rationale aloud as if you’re tutoring a classmate. If you can teach it, you own it.
4. Mix & spiral: Next session, re-mix topics so you learn to switch gears quickly—the way ATI does.
5. Light review near exam day: Two or three short sets focusing on safety, PPE, and high-alert med rules. Sleep.

Fundamentals is the backbone of everything you’ll do as a nurse—and ATI knows it. This practice pack gives you the right kind of reps: realistic stems, crystal-clear rationales, and repetition of the habits that score. If you want a direct route to better decisions and faster test-taking, grab the ATI Fundamentals Proctored Exam Practice Questions today. Use it to learn smarter, not longer; to convert uncertainty into consistent, safety-first answers; and to walk into the RN Fundamentals ATI proctored exam with the calm of someone who’s already seen how the test thinks. Download once, study anywhere, and keep it for refreshers throughout the semester—because strong fundamentals pay you back on every exam that follows.

Sample Questions and Answers

A nurse prepares to ambulate a postoperative client for the first time. Which action should the nurse take first?

A. Apply a gait belt
B. Assess the client’s orthostatic vital signs
C. Provide non-skid socks
D. Explain how to use the call light

Answer: B. Assess the client’s orthostatic vital signs
Explanation: Before initiating ambulation after surgery, the nurse’s priority is safety—specifically, assessing for orthostatic hypotension that could precipitate syncope and falls. A baseline and positional blood pressure/heart rate (lying, sitting, standing) identify volume depletion and autonomic changes from anesthesia or opioids. While gait belts, footwear, and instruction are important safety measures, they follow the assessment step in the nursing process (assessment precedes planning and implementation). Acting without assessing may put the client at unnecessary risk.

A client placed on contact precautions for C. difficile asks why alcohol gel isn’t used. Which response is best?

A. “Alcohol damages spores.”
B. “Soap and water are more effective against spores.”
C. “Gloves replace hand hygiene for this germ.”
D. “Gel is fine if hands look clean.”

Answer: B. “Soap and water are more effective against spores.”
Explanation: Clostridioides difficile forms hardy spores that are not reliably inactivated by alcohol-based hand rubs. Friction with soap and water removes spores mechanically from the hands. Gloves do not replace hand hygiene; they reduce contamination but can have microtears or be contaminated during removal. After removing PPE, the nurse must perform hand hygiene with soap and water upon exiting the room. Teaching should emphasize dedicated equipment, environmental cleaning with sporicidal agents, and judicious antibiotic use to prevent recurrence.

A nurse receives four clients. Which should be assessed first using ABCs and safety?

A. COPD client with SpO₂ 90% on 2 L/min
B. Post-op client reporting 8/10 pain
C. Client on heparin with new bruising
D. Client with new confusion trying to get out of bed

Answer: D. Client with new confusion trying to get out of bed
Explanation: Prioritization blends ABCs, safety, and acute changes. New confusion with unsafe mobility poses an immediate risk of injury (falls, head trauma, pulling lines). Although a COPD client with SpO₂ 90% may be at baseline, it’s not emergent. Severe pain is time-sensitive but not as life- or safety-threatening as imminent harm. New bruising on heparin warrants assessment but lacks the immediacy of a confused client about to fall. Rapid intervention (reorientation, supervision, bed alarm) prevents harm.

Which instruction is correct for a client using a cane?

A. Hold cane on the weaker side
B. Move cane and weaker leg together, then the stronger leg
C. Keep elbow fully extended when holding the cane
D. Advance stronger leg with the cane

Answer: B. Move cane and weaker leg together, then the stronger leg
Explanation: Proper biomechanics: the cane is held on the stronger side to widen the base of support and shift weight off the weaker extremity. The sequence is cane → weaker leg → stronger leg, keeping the elbow flexed ~15–30° for control. On stairs: “up with the good” (strong leg first going up), and “down with the bad” (cane and weaker leg first going down). Teaching and supervised practice reduce falls and improve gait stability.

A nurse delegates obtaining routine vital signs on stable clients to an experienced UAP. Which statement reflects appropriate delegation?

A. “If a blood pressure is high, recheck in 30 minutes.”
B. “Report any temperature above 38°C (100.4°F) immediately.”
C. “If the pulse is irregular, notify the provider.”
D. “Teach the client deep breathing after you finish.”

Answer: B. “Report any temperature above 38°C (100.4°F) immediately.”
Explanation: Delegation requires clear expectations, reporting parameters, and supervision. UAPs can measure and report vital signs; the RN interprets findings and determines actions. Asking the UAP to re-assess or teach (options A and D) crosses into nursing judgment and education, which are RN responsibilities. While the UAP should report irregular pulses, directing them to notify the provider bypasses RN assessment and chain of command. The RN should be notified, interpret, and escalate as needed.

A client is prescribed 1,000 mL LR to infuse over 8 hours. What is the infusion rate in mL/hr?

A. 100
B. 120
C. 125
D. 150

Answer: C. 125
Explanation: Calculate mL/hr: 1,000 mL ÷ 8 hr = 125 mL/hr. Dimensional analysis ensures accuracy and prevents under- or over-infusion. For safety, verify the fluid type, IV site patency, and pump programming. Monitor for signs of fluid overload (e.g., crackles, edema) especially in clients with cardiac or renal compromise. Record intake on I&O flowsheets and evaluate therapy effectiveness (vitals, urine output, perfusion, lab values).

A nurse prepares to apply wrist restraints to a delirious client pulling at IV lines. Which action is priority?

A. Tie restraints to bed rails for quick release
B. Ensure two fingers fit under the restraint
C. Obtain a provider’s order as required by policy
D. Apply mitts instead of wrist restraints

Answer: C. Obtain a provider’s order as required by policy
Explanation: Restraints are last-resort safety devices requiring a time-limited order and strict documentation. Least restrictive alternatives (reorientation, sitter, covering lines) must be tried first. If restraints are necessary, obtain the order and use quick-release knots tied to the bed frame (never rails) with two-finger looseness, frequent neurovascular checks, skin care, toileting, and range-of-motion. Continuously reassess need and discontinue promptly. Policies protect client rights and reduce harm.

A nurse teaches incentive spirometer use after abdominal surgery. Which statement shows correct understanding?

A. “I should exhale hard into the device.”
B. “I’ll inhale slowly to raise the marker, 10 times each hour awake.”
C. “I’ll use it only if I feel short of breath.”
D. “I should cough first, then inhale quickly.”

Answer: B. “I’ll inhale slowly to raise the marker, 10 times each hour awake.”
Explanation: Incentive spirometry promotes alveolar expansion and prevents atelectasis. The client should sit upright, seal lips, inhale slowly and deeply to raise the indicator, hold for 3–5 seconds, then remove the mouthpiece and exhale normally. Repeat about 10 times hourly while awake, followed by controlled coughing to mobilize secretions. Fast inhalation or forceful exhalation defeats the purpose. Pain control and splinting the incision improve participation.

Which set of findings indicates fluid volume deficit?

A. Bounding pulse, crackles, weight gain
B. Dry mucous membranes, hypotension, tachycardia
C. JVD, edema, hyponatremia
D. Increased blood pressure, decreased hematocrit

Answer: B. Dry mucous membranes, hypotension, tachycardia
Explanation: Hypovolemia presents with poor skin turgor, dry mucosa, tachycardia, orthostatic hypotension, decreased urine output, and elevated BUN/hematocrit from hemoconcentration. In contrast, hypervolemia shows edema, JVD, crackles, weight gain, and possibly hyponatremia. The nurse evaluates intake/output, daily weights (most sensitive), vitals, and lab trends, initiating replacement fluids as ordered and addressing causes (e.g., GI losses, diuretics). Safety includes slow position changes and fall prevention.

A client with a new NG tube to low intermittent suction reports sore throat and dryness. Which nursing action is most appropriate?

A. Increase suction to continuous
B. Provide frequent oral care and water-soluble lubricant to lips
C. Offer ice chips every hour
D. Instill tap water through the tube

Answer: B. Provide frequent oral care and water-soluble lubricant to lips
Explanation: NG tubes bypass oral intake and contribute to mucosal dryness. Oral care with soft swabs, water-soluble lubricants, and humidified air increases comfort and prevents breakdown. Ice chips are usually contraindicated with gastric decompression unless specifically ordered due to aspiration or nausea risk. Never instill water without provider orders. Suction should be low intermittent to protect gastric mucosa. Assess placement, patency, and output regularly.

A nurse prepares to administer a unit-dose oral medication. The client states, “That pill looks different from what I take at home.” Best action?

A. Tell the client hospital brands vary
B. Recheck the order, the MAR, and the medication against the client’s ID
C. Ask the UAP to verify the drug
D. Document refusal and notify pharmacy later

Answer: B. Recheck the order, the MAR, and the medication against the client’s ID
Explanation: A client’s concern is a safety red flag. The nurse must hold the medication, verify the provider order, compare with the MAR, scan the barcode if used, and confirm the rights of medication administration. Differences in color/shape can be legitimate (generic variations), but verification prevents errors. Engage pharmacy for clarification, use reputable references, and educate the client before giving the dose. Never delegate medication verification to UAP.

A client receiving 2 L/min oxygen by nasal cannula develops nasal dryness. Which intervention is appropriate?

A. Apply petroleum jelly inside nares
B. Add humidification to the oxygen delivery
C. Switch to a nonrebreather mask
D. Reduce flow to 1 L/min without an order

Answer: B. Add humidification to the oxygen delivery
Explanation: Low-flow oxygen dries mucosa; humidification mitigates irritation, bleeding, and discomfort. Water-based lubricants may be used externally, but petroleum products pose a combustion risk and should be avoided with oxygen. Changing devices or altering flow rates requires a provider order unless governed by protocols. Monitor for skin breakdown at tubing sites and ensure proper fit to maintain prescribed FiO₂ while protecting tissue integrity.

A nurse reviews a new prescription: “Morphine 2–4 mg IV q2h PRN severe pain.” The client rates pain 9/10, BP 118/72, RR 14, sedation scale 1. What is the best action?

A. Administer 2 mg IV and reassess in 4 hours
B. Administer 4 mg IV now and reassess in 15–30 minutes
C. Hold dose due to sedation risk
D. Give an oral analgesic first

Answer: B. Administer 4 mg IV now and reassess in 15–30 minutes
Explanation: For severe pain (9/10) with stable vitals and minimal sedation, using the higher end of the prescribed range is appropriate. IV opioids have rapid onset; reassessment for efficacy and adverse effects (RR, sedation, BP, pruritus, nausea) within 15–30 minutes is essential. If inadequate, notify the provider for titration or multimodal analgesia. Underdosing severe pain delays relief and may heighten physiologic stress responses.

A nurse provides discharge teaching on warfarin. Which statement indicates correct understanding?

A. “I’ll eat more leafy greens to help the medicine.”
B. “I’ll keep my vitamin K intake consistent each week.”
C. “I don’t need blood tests unless I feel bad.”
D. “I’ll use ibuprofen for headaches.”

Answer: B. “I’ll keep my vitamin K intake consistent each week.”
Explanation: Warfarin antagonizes vitamin K–dependent clotting factors; sudden increases or decreases in vitamin K (leafy greens, certain oils) alter INR control. Consistency—not avoidance—is key. Regular INR monitoring is required to maintain therapeutic range and reduce bleeding/thrombotic risks. NSAIDs like ibuprofen increase bleeding risk; acetaminophen is generally safer in moderation with provider guidance. Clients should report signs of bleeding and drug/food interactions.

The nurse is teaching a client about home use of a metered-dose inhaler (MDI) without spacer. Which step is essential?

A. Exhale into the inhaler before actuating
B. Inhale slowly and deeply while pressing the canister once
C. Hold breath for 1 second after inhalation
D. Take rapid breaths to push medication deeper

Answer: B. Inhale slowly and deeply while pressing the canister once
Explanation: Proper MDI technique increases lung deposition: shake inhaler, exhale fully away, place mouthpiece, begin a slow deep inhalation (3–5 seconds) while actuating once, then hold breath about 10 seconds before exhaling. Wait 30–60 seconds between puffs if prescribed. If both bronchodilator and steroid are ordered, take bronchodilator first; rinse mouth after steroids to prevent candidiasis. A spacer can improve coordination and delivery for many clients.

A nurse performs sterile wound irrigation. Which action maintains sterility?

A. Pour solution from a previously opened bottle without checking date
B. Keep sterile field at waist level and within vision
C. Touch sterile gloves to the client’s intact skin
D. Allow solution to flow from dirty to clean area

Answer: B. Keep sterile field at waist level and within vision
Explanation: Sterility principles include keeping the field above waist level, in view, and dry; avoiding contact with non-sterile surfaces; and directing solution from least contaminated to most contaminated area (clean to dirty). Opened solution bottles have limited sterility once opened—check policy and date/time. If sterile gloves contact intact skin or a non-sterile item, contamination is assumed and gloves must be changed to protect the wound from pathogens.

The nurse receives shift report. Which task is appropriate to delegate to a UAP?

A. Feed a new-stroke client with dysphagia
B. Perform bed-to-chair transfer for a stable client with established ability
C. Educate a client on a low-sodium diet
D. Evaluate pain relief after medication

Answer: B. Perform bed-to-chair transfer for a stable client with established ability
Explanation: UAP can perform routine, predictable tasks with low risk, including established ambulation and transfers using proper equipment. Feeding a dysphagic client requires RN assessment and often speech therapy to reduce aspiration risk. Teaching and evaluation are RN roles. The RN must provide clear instructions, ensure safety devices are used, and remain available to supervise and reassess if the client’s status changes.

A client with type 2 diabetes asks about foot care. Which instruction is correct?

A. Soak feet daily for 30 minutes
B. Trim toenails rounded at the corners
C. Inspect feet daily and use lotion, avoiding between toes
D. Walk barefoot indoors to air feet

Answer: C. Inspect feet daily and use lotion, avoiding between toes
Explanation: Diabetic neuropathy and vascular changes raise risk of injury and infection. Clients should inspect feet daily (including soles with a mirror), keep skin moisturized but avoid lotion between toes to prevent maceration, wear well-fitted shoes and socks, and never go barefoot. Nails should be trimmed straight across and filed to prevent ingrown nails. Soaking can dry skin and increase breakdown risk. Promptly report cuts, blisters, or color changes.

A nurse cares for an older adult at risk for constipation. Which dietary change is most helpful?

A. Increase cheese intake
B. Add whole grains, fruits, and 2–3 L/day of fluids if not contraindicated
C. Reduce fiber to rest the bowel
D. Switch to a high-protein, low-carb diet

Answer: B. Add whole grains, fruits, and 2–3 L/day of fluids if not contraindicated
Explanation: Adequate fiber and fluid increase stool bulk and softness, promoting regularity. Activity also stimulates peristalsis. Cheese and low-fiber patterns worsen constipation. For clients with cardiac/renal limits, tailor fluid goals. Establish a toileting routine, avoid excessive laxatives that may lead to dependence, and evaluate medications (anticholinergics, opioids, iron) that contribute to constipation. Education fosters sustainable habits and reduces complications like hemorrhoids.

A nurse teaches cultural humility. Which behavior best reflects it?

A. Memorizing traits of each culture
B. Asking open-ended questions about the client’s beliefs and preferences
C. Avoiding discussions of culture to prevent offense
D. Explaining the hospital’s standard way of doing things first

Answer: B. Asking open-ended questions about the client’s beliefs and preferences
Explanation: Cultural humility emphasizes self-reflection, curiosity, and partnership rather than stereotyping. Open-ended questions (e.g., “How do you prefer we approach your care?”) let clients define what matters. Avoid assumptions and integrate preferences into the plan when safe. Provide interpreter services for language access and assess health literacy. Respect rituals, diet, and family decision patterns while upholding safety and ethics. This approach builds trust and adherence.

A client is NPO for surgery. Which medication would the nurse clarify before administration?

A. Proton pump inhibitor
B. Beta-blocker with sips of water
C. Warfarin dose due this morning
D. Inhaled bronchodilator

Answer: C. Warfarin dose due this morning
Explanation: Anticoagulants increase bleeding risk during surgery and are typically managed with specific pre-op protocols. The nurse should verify with the provider/anesthesia whether to hold warfarin and evaluate most recent INR. Beta-blockers are often continued to prevent rebound tachycardia; PPIs may be given to reduce aspiration risk; inhalers should be used as prescribed for pulmonary stability. Always confirm agency policy and individualized orders.

The nurse evaluates a client with a chest tube to water-seal drainage. Which finding requires action?

A. Gentle bubbling in suction control chamber
B. Tidaling in the water-seal chamber with respirations
C. Continuous bubbling in water-seal chamber
D. Drainage of 60 mL serosanguineous in 4 hours

Answer: C. Continuous bubbling in water-seal chamber
Explanation: Continuous bubbling in the water-seal chamber indicates an air leak. The nurse should assess connections, dressing, and tubing for dislodgment or cracks, and notify the provider if unresolved. Gentle bubbling in the suction chamber is expected when suction is applied; tidaling reflects pleural pressure changes and may cease as the lung re-expands. Monitor drainage amount and characteristics, keep system below chest level, avoid stripping, and maintain an occlusive dressing.

A client on fall precautions must use the bathroom urgently. Which is the safest intervention?

A. Provide a bedside commode with assistance
B. Tell the client to wait until staff are free
C. Offer an indwelling catheter
D. Remove the bed alarm to prevent embarrassment

Answer: A. Provide a bedside commode with assistance
Explanation: Timely toileting reduces falls associated with urgency. A bedside commode preserves dignity while minimizing distance. The nurse or UAP should assist with transfer, ensure non-skid footwear, lock wheels, and keep the call light within reach. Bed alarms should remain in place as part of the fall-prevention bundle. Indwelling catheters are not appropriate solely for convenience due to infection risk; use only with clear indications.

A nurse is teaching correct use of a 24-hour urine collection. Which instruction is essential?

A. Discard the first void and note the start time
B. Save only morning urine
C. Keep the container at room temperature
D. If one void is missed, continue anyway

Answer: A. Discard the first void and note the start time
Explanation: For accurate 24-hour collection, the first void is discarded and time recorded; all subsequent urine is saved—including the final void at 24 hours—and the container is kept on ice or refrigerated per protocol. Missing any void invalidates the test; the collection must be restarted. Teaching should include avoiding contamination with stool or toilet paper and notifying staff immediately if a specimen is accidentally discarded.

A nurse reviews enteral feeding through a PEG tube. Which action reduces aspiration risk?

A. Lay the client flat during feeding
B. Verify gastric residuals are zero before every bolus
C. Elevate HOB 30–45° during and 30–60 minutes after feeding
D. Add blue dye to detect aspiration

Answer: C. Elevate HOB 30–45° during and 30–60 minutes after feeding
Explanation: Head-of-bed elevation is a key aspiration-prevention measure. Additional steps: verify tube placement per policy, assess tolerance, use appropriate formula and rate, and consider prokinetics if ordered. “Zero residual” is unrealistic; follow facility thresholds. Dyes are not recommended due to safety concerns. Maintain oral hygiene, monitor abdominal distension, bowel function, and glucose, and ensure correct flushing to maintain tube patency.

Which statement by a client starting a steroid dose pack for COPD indicates need for further teaching?

A. “I’ll take it in the morning with food.”
B. “I’ll stop as soon as I feel better.”
C. “I’ll report black, tarry stools.”
D. “I will not skip doses.”

Answer: B. “I’ll stop as soon as I feel better.”
Explanation: Systemic corticosteroids require adherence to prescribed dosing and taper to prevent adrenal suppression and rebound inflammation. Stopping early is unsafe. Taking in the morning with food reduces GI upset and mimics circadian rhythm. Clients should report signs of GI bleeding, infection, mood changes, or hyperglycemia. Reinforce that steroids reduce inflammation but do not replace rescue bronchodilators for acute dyspnea.

A nurse evaluates learning after teaching a new colostomy. Which client action demonstrates effective self-care?

A. Cutting the wafer opening 0.5–1.0 cm larger than the stoma
B. Using oil-based products to remove adhesive
C. Emptying the pouch when it is one-third to one-half full
D. Avoiding fluids to reduce output

Answer: C. Emptying the pouch when it is one-third to one-half full
Explanation: Emptying before the pouch becomes heavy prevents leakage and protects skin. The wafer opening should be about 1/8 inch (3–4 mm) larger than the stoma to avoid constriction while protecting peristomal skin; 0.5–1.0 cm is too large. Use adhesive removers designed for ostomies rather than oils that can interfere with adhesion. Adequate hydration is important; clients should monitor foods that cause gas/odor and use skin barriers to prevent breakdown.

A client receiving IV potassium chloride (KCl) 20 mEq in 100 mL NS has burning at the site. What is the best action?

A. Stop the infusion and remove the catheter immediately
B. Slow the rate per protocol and verify patency; ensure dilution
C. Bolus the remainder to finish quickly
D. Switch to IM injection

Answer: B. Slow the rate per protocol and verify patency; ensure dilution
Explanation: KCl is vesicant-like and can irritate veins. Confirm a patent IV with blood return, reduce the rate within safe limits, and consider further dilution or a larger vein. Never IV push or IM KCl. Assess the site for phlebitis or infiltration and replace the line if compromised. Continuous cardiac monitoring may be indicated depending on dose. Educate the client about expected mild discomfort versus signs that require immediate reporting.

A nurse completes admission documentation. Which entry is most appropriate and legally sound?

A. “Client uncooperative and rude.”
B. “Client appears intoxicated.”
C. “Client states, ‘I drank six beers tonight’; slurred speech noted.”
D. “Client probably used illegal drugs.”

Answer: C. “Client states, ‘I drank six beers tonight’; slurred speech noted.”
Explanation: Objective, factual documentation includes direct quotations and observable findings, avoiding judgment or unsupported conclusions. Subjective impressions like “rude” or “intoxicated” are non-specific and potentially biased. Accurate charting supports continuity of care, legal protection, and quality improvement. Record time, assessments, interventions, the client’s response, and notifications. Do not alter records; use approved corrections. Confidentiality and access control must be maintained.

The nurse plans teaching for a newly prescribed antihypertensive. Which strategy best supports health literacy?

A. Provide a detailed, single 6-page pamphlet
B. Use medical terms to be precise
C. Teach-back using plain language and 1–3 key points per visit
D. Schedule teaching only at discharge

Answer: C. Teach-back using plain language and 1–3 key points per visit
Explanation: Health-literacy-sensitive education uses plain language, visual aids, and the teach-back method—asking the client to restate instructions to confirm understanding. Limiting to a few essential points and reinforcing over time improves adherence. Tailor instructions to routines (same time daily, home BP logs), address side effects (orthostatic precautions), and involve family if the client agrees. Early and repeated teaching—rather than waiting until discharge—enhances safety and outcomes.