ATI Fundamentals Test Exam 2 2026
A nurse in a medical-surgical unit is caring for six clients.
Complete the following sentence by using the list of options.
The first client the nurse should assess is followed by .
Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a
history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client
is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous
administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart
failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is
admitted with a new diagnosis of diabetes mellitus. - Correct Answer (1):
Client 3
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the priority client to assess. The client has an oxygen saturation
that is less than the expected reference range, which is an indication of hypoxia.
Correct Answer (2):
Client 4
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the next priority client to assess. The client has a potassium level
that is less than the expected reference range, which places the client at risk for dysrhythmias.
Incorrect Answers (1):
Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein
is greater than the expected reference range, which is an indication of inflammation.
However, there is another client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level
is greater than the expected reference range, which places them at risk for coronary heart
disease. However, there is another client the nurse should assess first.
Incorrect Answers (2):
Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less
than the expected reference range, which places them at risk for delayed wound healing.
However, this client is not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated
hemoglobin level is greater than the expected reference range, which indicates poor diabetic
control. However, this client is not the next priority client to assess.
A nurse is caring for a client who has COPD.
Select the 3 findings that require follow-up.
Breath sounds
Blood pressure
,Oxygen saturation
Temperature
Heart rate - Correct Answer:
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumonia.
Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range of 95% to 100%,
indicating hypoxia, and requires follow-up by the nurse.
Temperature
The client's temperature is greater than the expected reference range, indicating an infection,
and requires follow-up by the nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference range
and does not require follow-up by the nurse.
Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to
100/min and does not require follow-up by the nurse.
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.
Based on the client's clinical findings, which of the following actions should the nurse take?
Select all that apply.
Assist the client to a left side-lying position with the right knee flexed.
Prepare the client for a chest x-ray.
Administer a cleansing enema.
Auscultate the client's bowel sounds.
Perform a manual digital examination of the client's rectum.
Administer oxycodone extended-release tablets.
Prepare the client for NG tube placement. - Correct Answer:
Assist the client to a left side-lying position with the right knee flexed
The nurse should place the client in a left side-lying position with the right knee flexed prior
to administering an enema. Because the provider prescribed a cleansing enema for the client,
the nurse should prepare the client for the procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the client as a result of the provider's
prescription. A cleansing enema is intended to assist with bowel elimination and remove any
impacted fecal matter indicated by the abdominal x-ray.
Auscultate the client's bowel sounds
The nurse should auscultate the client's bowel sounds to determine the status of the client's
peristalsis. This is a necessary part of determining the presence of bowel sounds, which are
an indication of the status of the client's gastrointestinal tract.
Perform a manual digital examination of the client's rectum
,The nurse should perform a manual digital examination of the client's rectum to determine if
impacted stool is present. This is a part of the necessary evaluation of the status of the client's
gastrointestinal tract.
Incorrect Answer:
Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a
client who has an impairment of the upper thorax or lungs, not the abdomen. The client has
already received an abdominal x-ray; therefore, a chest x-ray is not necessary.
Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client
for placement of an NG tube because there is no indication or prescription to do so.
Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract
and peristalsis is absent.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following statements should the nurse make?
"They allow the court to overrule an adult client's refusal of medical treatment."
"They indicate the form of treatment a client is willing to accept in the event of a serious
illness."
"They permit a client to withhold medical information from health care personnel."
"They allow health care personnel in the emergency department to stabilize a client's
condition." - Correct Answer:
"They indicate the form of treatment a client is willing to accept in the event of a serious
illness."
Advance directives include a living will, which permits clients to direct the treatment they
will receive in the event of a medical emergency or serious illness.
Incorrect Answer:
"They allow the court to overrule an adult client's refusal of medical treatment."
A court can only overrule an adult client's refusal of medical treatment if the client is legally
incompetent.
"They permit a client to withhold medical information from health care personnel."
The Americans with Disabilities Act, not advance directives, protects the privacy of a client
who chooses not to disclose a medical disability.
"They allow health care personnel in the emergency department to stabilize a client's
condition."
The Emergency Medical Treatment and Active Labor Act, not advance directives, directs
emergency personnel to provide screening and stabilizing care before discharging or
transferring clients to another facility.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units
of NPH insulin to mix together and administer subcutaneously. Determine the correct order
of steps for this procedure.
Inject 5 units of air into the bottle of regular insulin
Withdraw the correct dose of NPH insulin from the bottle
Inject 10 units of air into the bottle of NPH insulin
, Withdraw the correct dose of regular insulin from the bottle - Correct Answer:
Inject 10 units of air into the bottle of NPH insulin
Inject 5 units of air into the bottle of regular insulin
Withdraw the correct dose of regular insulin from the bottle
Withdraw the correct dose of NPH insulin from the bottle
The nurse should first inject air into the vial of NPH insulin without touching the needle to
the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the
correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH
insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these
steps to prevent contaminating the regular insulin with NPH insulin.
A nurse is performing a Romberg test during the physical assessment of a client. Which of
the following techniques should the nurse use?
Touch the face with a cotton ball.
Apply a vibrating tuning fork to the client's forehead.
Have the client stand with their arms at their sides and their feet together.
Perform direct percussion over the area of the kidneys. - Correct Answer:
Have the client stand with their arms at their sides and their feet together.
A Romberg test helps identify alterations in balance. The nurse should have the client stand
with their arms at their sides and their feet together to observe for swaying and a loss of
balance.
Incorrect Answer:
Touch the face with a cotton ball.
The nurse should touch the client's corneas with a wisp of cotton and measure light touch and
pain across the client's face to test cranial nerve V, the trigeminal nerve.
Apply a vibrating tuning fork to the client's forehead.
The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test
to identify sound lateralization when assessing hearing.
Perform direct percussion over the area of the kidneys.
The nurse should perform direct percussion over the area of the kidneys to evaluate them for
inflammation.
A nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the
client and their family.
Check the cord routinely for frays or tearing.
Keep the unit at least 1.2 m (4 ft) away from a gas stove.
Consider purchasing a generator for power backup.
Observe for signs of hypoxia.
Select synthetic clothing and bedding. - Correct Answer:
Check the cord routinely for frays or tearing.
Oxygen concentrators require electrical power. Safe use of this delivery system includes
assessing the electrical function of the device; therefore, the nurse should instruct the client to
routinely check the condition of the cord.
A nurse in a medical-surgical unit is caring for six clients.
Complete the following sentence by using the list of options.
The first client the nurse should assess is followed by .
Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a
history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client
is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous
administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart
failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is
admitted with a new diagnosis of diabetes mellitus. - Correct Answer (1):
Client 3
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the priority client to assess. The client has an oxygen saturation
that is less than the expected reference range, which is an indication of hypoxia.
Correct Answer (2):
Client 4
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the next priority client to assess. The client has a potassium level
that is less than the expected reference range, which places the client at risk for dysrhythmias.
Incorrect Answers (1):
Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein
is greater than the expected reference range, which is an indication of inflammation.
However, there is another client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level
is greater than the expected reference range, which places them at risk for coronary heart
disease. However, there is another client the nurse should assess first.
Incorrect Answers (2):
Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less
than the expected reference range, which places them at risk for delayed wound healing.
However, this client is not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated
hemoglobin level is greater than the expected reference range, which indicates poor diabetic
control. However, this client is not the next priority client to assess.
A nurse is caring for a client who has COPD.
Select the 3 findings that require follow-up.
Breath sounds
Blood pressure
,Oxygen saturation
Temperature
Heart rate - Correct Answer:
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumonia.
Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range of 95% to 100%,
indicating hypoxia, and requires follow-up by the nurse.
Temperature
The client's temperature is greater than the expected reference range, indicating an infection,
and requires follow-up by the nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference range
and does not require follow-up by the nurse.
Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to
100/min and does not require follow-up by the nurse.
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.
Based on the client's clinical findings, which of the following actions should the nurse take?
Select all that apply.
Assist the client to a left side-lying position with the right knee flexed.
Prepare the client for a chest x-ray.
Administer a cleansing enema.
Auscultate the client's bowel sounds.
Perform a manual digital examination of the client's rectum.
Administer oxycodone extended-release tablets.
Prepare the client for NG tube placement. - Correct Answer:
Assist the client to a left side-lying position with the right knee flexed
The nurse should place the client in a left side-lying position with the right knee flexed prior
to administering an enema. Because the provider prescribed a cleansing enema for the client,
the nurse should prepare the client for the procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the client as a result of the provider's
prescription. A cleansing enema is intended to assist with bowel elimination and remove any
impacted fecal matter indicated by the abdominal x-ray.
Auscultate the client's bowel sounds
The nurse should auscultate the client's bowel sounds to determine the status of the client's
peristalsis. This is a necessary part of determining the presence of bowel sounds, which are
an indication of the status of the client's gastrointestinal tract.
Perform a manual digital examination of the client's rectum
,The nurse should perform a manual digital examination of the client's rectum to determine if
impacted stool is present. This is a part of the necessary evaluation of the status of the client's
gastrointestinal tract.
Incorrect Answer:
Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a
client who has an impairment of the upper thorax or lungs, not the abdomen. The client has
already received an abdominal x-ray; therefore, a chest x-ray is not necessary.
Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client
for placement of an NG tube because there is no indication or prescription to do so.
Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract
and peristalsis is absent.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following statements should the nurse make?
"They allow the court to overrule an adult client's refusal of medical treatment."
"They indicate the form of treatment a client is willing to accept in the event of a serious
illness."
"They permit a client to withhold medical information from health care personnel."
"They allow health care personnel in the emergency department to stabilize a client's
condition." - Correct Answer:
"They indicate the form of treatment a client is willing to accept in the event of a serious
illness."
Advance directives include a living will, which permits clients to direct the treatment they
will receive in the event of a medical emergency or serious illness.
Incorrect Answer:
"They allow the court to overrule an adult client's refusal of medical treatment."
A court can only overrule an adult client's refusal of medical treatment if the client is legally
incompetent.
"They permit a client to withhold medical information from health care personnel."
The Americans with Disabilities Act, not advance directives, protects the privacy of a client
who chooses not to disclose a medical disability.
"They allow health care personnel in the emergency department to stabilize a client's
condition."
The Emergency Medical Treatment and Active Labor Act, not advance directives, directs
emergency personnel to provide screening and stabilizing care before discharging or
transferring clients to another facility.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units
of NPH insulin to mix together and administer subcutaneously. Determine the correct order
of steps for this procedure.
Inject 5 units of air into the bottle of regular insulin
Withdraw the correct dose of NPH insulin from the bottle
Inject 10 units of air into the bottle of NPH insulin
, Withdraw the correct dose of regular insulin from the bottle - Correct Answer:
Inject 10 units of air into the bottle of NPH insulin
Inject 5 units of air into the bottle of regular insulin
Withdraw the correct dose of regular insulin from the bottle
Withdraw the correct dose of NPH insulin from the bottle
The nurse should first inject air into the vial of NPH insulin without touching the needle to
the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the
correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH
insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these
steps to prevent contaminating the regular insulin with NPH insulin.
A nurse is performing a Romberg test during the physical assessment of a client. Which of
the following techniques should the nurse use?
Touch the face with a cotton ball.
Apply a vibrating tuning fork to the client's forehead.
Have the client stand with their arms at their sides and their feet together.
Perform direct percussion over the area of the kidneys. - Correct Answer:
Have the client stand with their arms at their sides and their feet together.
A Romberg test helps identify alterations in balance. The nurse should have the client stand
with their arms at their sides and their feet together to observe for swaying and a loss of
balance.
Incorrect Answer:
Touch the face with a cotton ball.
The nurse should touch the client's corneas with a wisp of cotton and measure light touch and
pain across the client's face to test cranial nerve V, the trigeminal nerve.
Apply a vibrating tuning fork to the client's forehead.
The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test
to identify sound lateralization when assessing hearing.
Perform direct percussion over the area of the kidneys.
The nurse should perform direct percussion over the area of the kidneys to evaluate them for
inflammation.
A nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the
client and their family.
Check the cord routinely for frays or tearing.
Keep the unit at least 1.2 m (4 ft) away from a gas stove.
Consider purchasing a generator for power backup.
Observe for signs of hypoxia.
Select synthetic clothing and bedding. - Correct Answer:
Check the cord routinely for frays or tearing.
Oxygen concentrators require electrical power. Safe use of this delivery system includes
assessing the electrical function of the device; therefore, the nurse should instruct the client to
routinely check the condition of the cord.
