ATI RN Fundamentals Online
Practice SOLUTIONS GRADE A+
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
Practice SOLUTIONS GRADE A+
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
