ATIRNFundamentalsOnlinePractice2025/2026BQuestions
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A nurse in a medical-surgical unit is caring forAsix clients.
Complete the following sentence byAusing the list ofAoptions.
The first client the nurse should assess is _____ followed byA _____________________________________ _.
Client 1:AClient is admitted with a new diagnosis ofArheumatoid arthritis.Client 2:AClient h as a
historyAofAhyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3:AClient is 1
dayApostoperative. Reports pain as 8 on a scale ofA0 toA10. Morphine 5 mg subcutaneous administered as
prescribed.Client 4:AClient is admitted with a new diagno sis ofAheart failure.Client 5:AClient has a stage 2
pressure injuryAon the left heel.Client 6:A Client is admitted with a new diagnosis ofAdiabetes mellitus. -
CORRECT ANSWERS Correct AnswerA(1):
Client 3
When using the airway, breathing, circulation approach toAclient care, the nurse should determine that this
client isAthe priorityAclient toAassess. The client has an oxygen saturat ion that is less than the expected
reference range, which isAan indication ofAhypoxia.
Correct AnswerA(2):
Client 4
When using the airway, breathing, circulation approach toAclient care, the nurse should determine that this
client isAthe next priorityAclient toAassess. The client has a potassium level that is less than the expected
reference range, which places the client at risk forAdy srhythmias.
InCORRECT ANSWERS (1):
Client 1 is incorrect. The nurse should assess thisAclient because the client's C- reactive protein
isAgreaterAthan the expected reference range, which is an indication ofAi nflammation. However, there is
anotherAclient the nurse should assess first.
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Client 2 is incorrect. The nurse should assess thisAclient because the client's cholesterol level is
greaterAthan the expected reference range, which places them at risk forAcorona ryAheart disease.
However, there is anotherAclient the nurse should assess first.
InCORRECT ANSWERS (2):
Client 5 is incorrect. The nurse should assess thisAclient because theirAprealbumin level i s less than the
expected reference range, which places them at risk forAdelayed wound healing. However, this client is not
the next priorityAclient toAassess.
Client 6 is incorrect. The nurse should assess thisAclient because theirAglycosylated hem oglobin level is
greaterAthan the expected reference range, which indicates poorAdiabetic control. However, this client is not
the next priorityAclient toAassess.
A nurse is caring forAa client whoAhas COPD.
Select the 3 findings that require follow-up.
Breath sounds Blood
pressure Oxygen
saturation Temperature
Heart rate - CORRECT ANSWERS Correct Answer:
Breath Sounds
Crackles are caused byAmucous in the airways and are a manifestation ofApneumonia. D ecreased breath
sounds indicate decreased ventilation and require follow-
up byAthe nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range ofA95% toA100%, i ndicating hypoxia, and
requires follow-up byAthe nurse.
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Temperature
The client's temperature is greaterAthan the expected reference range, indicating an infe ction, and requires
follow-up byAthe nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not
require follow-up byAthe nurse.
Heart rate is incorrect. The client's heart rate is within the expected reference range ofA6 0 toA100/min and
does not require follow-up byAthe nurse.
A nurse in the emergencyAdepartment (ED) is caring forAa client whoAreports abdominal pain.
Based on the client's clinical findings, which ofAthe following actions should the nurse tak e? Select all that
apply.
Assist the client toAa left side-lying position with the right knee flexed. Prepare the client forAa
chest x-ray.
AdministerAa cleansing enema. Auscultate the
client's bowel sounds.
Perform a manual digital examination ofAthe client'sArectum. AdministerAoxycodone extended-
release tablets.
Prepare the client forANG tube placement. -ACORRECT ANSWERS Correct Answer:
Assist the client toAa 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 priorAtoAadministering an enema. Because the pr
, ATIRNFundamentalsOnlinePractice2025/2026BQuestions
andAnswersallAnswers100%Correctly/VerifiedAnswers
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oviderAprescribed a cleansing enema forAthe client, the nurse should prepare the client f orAthe procedure.
AdministerAa cleansing enema
The nurse should administerAa cleansing enema forAthe client as a result ofAthe provider' s prescription. A
cleansing enema isAintended toAassist with bowel elimination and remo ve anyAimpacted fecal
matterAindicated byAthe abdominal x-ray.
Auscultate the client's bowel sounds
The nurse should auscultate the client's bowel sounds toAdetermine the status ofAthe clie nt's peristalsis.
This is a necessaryApart ofAdetermining the presence ofAbowel sounds, w hich are an indication ofAthe status
ofAthe client'sAgastrointestinal tract.
Perform a manual digital examination ofAthe client'sArectum
The nurse should perform a manual digital examination of Athe client's rectum toAdetermi ne ifAimpacted
stool is present. ThisAisAa part ofAthe necessaryAevaluation ofAthe status of the client's gastrointestinal tract.
Incorrect Answer:
Prepare the client forAa chest x-rayAis incorrect. A chest x-
rayAis typicallyAperformed forAa client whoAhas an impairment ofAthe upperAthorax orAlung s, not the abdomen.
The client hasAalreadyAreceived an abdominal x-
ray;Atherefore, a chest x-rayAis not necessary.
Prepare the client forANG tube placement isAincorrect. The nurse should not prepare the client forAplacement
ofAan NG tube because there is noAindication orAprescription toAdoAs
o. Placement ofAan NG tube isArequired when there is an obstruction ofAthe gastrointesti nal tract and
peristalsis is absent.
A nurse is caring forAa client whoAasks about the purpose ofAadvance directives. Which o fAthe following
statements should the nurse make?
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BrandNewRATED A+
A nurse in a medical-surgical unit is caring forAsix clients.
Complete the following sentence byAusing the list ofAoptions.
The first client the nurse should assess is _____ followed byA _____________________________________ _.
Client 1:AClient is admitted with a new diagnosis ofArheumatoid arthritis.Client 2:AClient h as a
historyAofAhyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3:AClient is 1
dayApostoperative. Reports pain as 8 on a scale ofA0 toA10. Morphine 5 mg subcutaneous administered as
prescribed.Client 4:AClient is admitted with a new diagno sis ofAheart failure.Client 5:AClient has a stage 2
pressure injuryAon the left heel.Client 6:A Client is admitted with a new diagnosis ofAdiabetes mellitus. -
CORRECT ANSWERS Correct AnswerA(1):
Client 3
When using the airway, breathing, circulation approach toAclient care, the nurse should determine that this
client isAthe priorityAclient toAassess. The client has an oxygen saturat ion that is less than the expected
reference range, which isAan indication ofAhypoxia.
Correct AnswerA(2):
Client 4
When using the airway, breathing, circulation approach toAclient care, the nurse should determine that this
client isAthe next priorityAclient toAassess. The client has a potassium level that is less than the expected
reference range, which places the client at risk forAdy srhythmias.
InCORRECT ANSWERS (1):
Client 1 is incorrect. The nurse should assess thisAclient because the client's C- reactive protein
isAgreaterAthan the expected reference range, which is an indication ofAi nflammation. However, there is
anotherAclient the nurse should assess first.
,ATIRNFundamentalsOnlinePractice2025/2026BQuestions
andAnswersallAnswers100%Correctly/VerifiedAnswers
BrandNewRATED A+
Client 2 is incorrect. The nurse should assess thisAclient because the client's cholesterol level is
greaterAthan the expected reference range, which places them at risk forAcorona ryAheart disease.
However, there is anotherAclient the nurse should assess first.
InCORRECT ANSWERS (2):
Client 5 is incorrect. The nurse should assess thisAclient because theirAprealbumin level i s less than the
expected reference range, which places them at risk forAdelayed wound healing. However, this client is not
the next priorityAclient toAassess.
Client 6 is incorrect. The nurse should assess thisAclient because theirAglycosylated hem oglobin level is
greaterAthan the expected reference range, which indicates poorAdiabetic control. However, this client is not
the next priorityAclient toAassess.
A nurse is caring forAa client whoAhas COPD.
Select the 3 findings that require follow-up.
Breath sounds Blood
pressure Oxygen
saturation Temperature
Heart rate - CORRECT ANSWERS Correct Answer:
Breath Sounds
Crackles are caused byAmucous in the airways and are a manifestation ofApneumonia. D ecreased breath
sounds indicate decreased ventilation and require follow-
up byAthe nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range ofA95% toA100%, i ndicating hypoxia, and
requires follow-up byAthe nurse.
,ATIRNFundamentalsOnlinePractice2025/2026BQuestions
andAnswersallAnswers100%Correctly/VerifiedAnswers
BrandNewRATED A+
Temperature
The client's temperature is greaterAthan the expected reference range, indicating an infe ction, and requires
follow-up byAthe nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not
require follow-up byAthe nurse.
Heart rate is incorrect. The client's heart rate is within the expected reference range ofA6 0 toA100/min and
does not require follow-up byAthe nurse.
A nurse in the emergencyAdepartment (ED) is caring forAa client whoAreports abdominal pain.
Based on the client's clinical findings, which ofAthe following actions should the nurse tak e? Select all that
apply.
Assist the client toAa left side-lying position with the right knee flexed. Prepare the client forAa
chest x-ray.
AdministerAa cleansing enema. Auscultate the
client's bowel sounds.
Perform a manual digital examination ofAthe client'sArectum. AdministerAoxycodone extended-
release tablets.
Prepare the client forANG tube placement. -ACORRECT ANSWERS Correct Answer:
Assist the client toAa 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 priorAtoAadministering an enema. Because the pr
, ATIRNFundamentalsOnlinePractice2025/2026BQuestions
andAnswersallAnswers100%Correctly/VerifiedAnswers
BrandNewRATED A+
oviderAprescribed a cleansing enema forAthe client, the nurse should prepare the client f orAthe procedure.
AdministerAa cleansing enema
The nurse should administerAa cleansing enema forAthe client as a result ofAthe provider' s prescription. A
cleansing enema isAintended toAassist with bowel elimination and remo ve anyAimpacted fecal
matterAindicated byAthe abdominal x-ray.
Auscultate the client's bowel sounds
The nurse should auscultate the client's bowel sounds toAdetermine the status ofAthe clie nt's peristalsis.
This is a necessaryApart ofAdetermining the presence ofAbowel sounds, w hich are an indication ofAthe status
ofAthe client'sAgastrointestinal tract.
Perform a manual digital examination ofAthe client'sArectum
The nurse should perform a manual digital examination of Athe client's rectum toAdetermi ne ifAimpacted
stool is present. ThisAisAa part ofAthe necessaryAevaluation ofAthe status of the client's gastrointestinal tract.
Incorrect Answer:
Prepare the client forAa chest x-rayAis incorrect. A chest x-
rayAis typicallyAperformed forAa client whoAhas an impairment ofAthe upperAthorax orAlung s, not the abdomen.
The client hasAalreadyAreceived an abdominal x-
ray;Atherefore, a chest x-rayAis not necessary.
Prepare the client forANG tube placement isAincorrect. The nurse should not prepare the client forAplacement
ofAan NG tube because there is noAindication orAprescription toAdoAs
o. Placement ofAan NG tube isArequired when there is an obstruction ofAthe gastrointesti nal tract and
peristalsis is absent.
A nurse is caring forAa client whoAasks about the purpose ofAadvance directives. Which o fAthe following
statements should the nurse make?
