PRACTICE 2023 B, ATI RN
FUNDAMENTALS PROCTORED EXAM
QUESTIONS AND ANSWERS
Aginursegiingiagimedical-surgicalgiunitgiisgicaringgiforgisixgiclients.
Completegithegifollowinggisentencegibygiusinggithegilistgiofgioptions.
Thegifirstgiclientgitheginursegishouldgiassessgiisgi_____gifollowedgibygi_____.
Clientgi1:giClientgiisgiadmittedgiwithgiaginewgidiagnosisgiofgirheumatoidgiarthritis.Clientgi2:giC
lientgihasgiagihistorygiofgihyperlipidemia.giAtorvastatingi20gimggiPOgiadministeredgiasgipres
cribed.Clientgi3:giClientgiisgi1gidaygipostoperative.giReportsgipaingiasgi8giongiagiscalegiofgi0gito
gi10.giMorphinegi5gimggisubcutaneousgiadministeredgiasgiprescribed.Clientgi4:giClientgiisgia
dmittedgiwithgiaginewgidiagnosisgiofgiheartgifailure.Clientgi5:giClientgihasgiagistagegi2gipressu
regiinjurygiongithegileftgiheel.Clientgi6:giClientgiisgiadmittedgiwithgiaginewgidiagnosisgiofgidiabet
esgimellitus.gi-gianswer--CorrectgiAnswergi(1):
Clientgi3
Whengiusinggithegiairway,gibreathing,gicirculationgiapproachgitogiclientgicare,githeginursegis
houldgideterminegithatgithisgiclientgiisgithegiprioritygiclientgitogiassess.giThegiclientgihasgiangio
xygengisaturationgithatgiisgilessgithangithegiexpectedgireferencegirange,giwhichgiisgiangiindic
ationgiofgihypoxia.
CorrectgiAnswergi(2):
Clientgi4
Whengiusinggithegiairway,gibreathing,gicirculationgiapproachgitogiclientgicare,githeginursegis
houldgideterminegithatgithisgiclientgiisgitheginextgiprioritygiclientgitogiassess.giThegiclientgihasgi
agipotassiumgilevelgithatgiisgilessgithangithegiexpectedgireferencegirange,giwhichgiplacesgith
egiclientgiatgiriskgiforgidysrhythmias.
IncorrectgiAnswersgi(1):
Clientgi1giisgiincorrect.giTheginursegishouldgiassessgithisgiclientgibecausegithegiclient'sgiC-
reactivegiproteingiisgigreatergithangithegiexpectedgireferencegirange,giwhichgiisgiangiindicati
ongiofgiinflammation.giHowever,githeregiisgianothergiclientgitheginursegishouldgiassessgifirst.
Clientgi2giisgiincorrect.giTheginursegishouldgiassessgithisgiclientgibecausegithegiclient'sgichol
esterolgilevelgiisgigreatergithangithegiexpectedgireferencegirange,giwhichgiplacesgithemgiatgiri
skgiforgicoronarygiheartgidisease.giHowever,githeregiisgianothergiclientgitheginursegishouldgia
ssessgifirst.
IncorrectgiAnswersgi(2):
,Clientgi5giisgiincorrect.giTheginursegishouldgiassessgithisgiclientgibecausegitheirgiprealbumin
gilevelgiisgilessgithangithegiexpectedgireferencegirange,giwhichgiplacesgithemgiatgiriskgiforgidel
ayedgiwoundgihealing.giHowever,githisgiclientgiisginotgitheginextgiprioritygiclientgitogiassess.
Clientgi6giisgiincorrect.giTheginursegishouldgiassessgithisgiclientgibecausegitheirgiglycosylate
dgihemoglobingilevelgiisgigreatergithangithegiexpectedgireferencegirange,giwhichgiindicatesgi
poorgidiabeticgicontrol.giHowever,githisgiclientgiisginotgitheginextgiprioritygiclientgitogiassess.
AginursegiisgicaringgiforgiagiclientgiwhogihasgiCOPD.
Selectgithegi3gifindingsgithatgirequiregifollow-up.
Breathgisounds
Bloodgipressure
Oxygengisaturation
Temperature
Heartgirategi-gianswer--CorrectgiAnswer:
BreathgiSounds
Cracklesgiaregicausedgibygimucousgiingithegiairwaysgiandgiaregiagimanifestationgiofgipneum
onia.giDecreasedgibreathgisoundsgiindicategidecreasedgiventilationgiandgirequiregifollow-
upgibygitheginurse.
OxygengiSaturation
Thegiclient'sgioxygengisaturationgiisgibelowgithegiexpectedgireferencegirangegiofgi95%gitogi1
00%,giindicatinggihypoxia,giandgirequiresgifollow-upgibygitheginurse.
Temperature
Thegiclient'sgitemperaturegiisgigreatergithangithegiexpectedgireferencegirange,giindicatinggia
ngiinfection,giandgirequiresgifollow-upgibygitheginurse.
IncorrectgiAnswer:
Bloodgipressuregiisgiincorrect.giThegiclient'sgibloodgipressuregiisgiwithingithegiexpectedgirefe
rencegirangegiandgidoesginotgirequiregifollow-upgibygitheginurse.
Heartgirategiisgiincorrect.giThegiclient'sgiheartgirategiisgiwithingithegiexpectedgireferencegiran
gegiofgi60gitogi100/mingiandgidoesginotgirequiregifollow-upgibygitheginurse.
Aginursegiingithegiemergencygidepartmentgi(ED)giisgicaringgiforgiagiclientgiwhogireportsgiabdo
minalgipain.gi
Basedgiongithegiclient'sgiclinicalgifindings,giwhichgiofgithegifollowinggiactionsgishouldgitheginu
rsegitake?giSelectgiallgithatgiapply.
Assistgithegiclientgitogiagileftgiside-lyinggipositiongiwithgithegirightgikneegiflexed.
Preparegithegiclientgiforgiagichestgix-ray.
Administergiagicleansinggienema.
Auscultategithegiclient'sgibowelgisounds.
Performgiagimanualgidigitalgiexaminationgiofgithegiclient'sgirectum.
Administergioxycodonegiextended-releasegitablets.
PreparegithegiclientgiforgiNGgitubegiplacement.gi-gianswer--CorrectgiAnswer:
,Assistgithegiclientgitogiagileftgiside-lyinggipositiongiwithgithegirightgikneegiflexedgi
Theginursegishouldgiplacegithegiclientgiingiagileftgiside-
lyinggipositiongiwithgithegirightgikneegiflexedgipriorgitogiadministeringgiangienema.giBecauseg
ithegiprovidergiprescribedgiagicleansinggienemagiforgithegiclient,githeginursegishouldgiprepar
egithegiclientgiforgithegiprocedure.
Administergiagicleansinggienemagi
Theginursegishouldgiadministergiagicleansinggienemagiforgithegiclientgiasgiagiresultgiofgithegipr
ovider'sgiprescription.giAgicleansinggienemagiisgiintendedgitogiassistgiwithgibowelgieliminati
ongiandgiremovegianygiimpactedgifecalgimattergiindicatedgibygithegiabdominalgix-ray.
Auscultategithegiclient'sgibowelgisoundsgi
Theginursegishouldgiauscultategithegiclient'sgibowelgisoundsgitogideterminegithegistatusgiofgit
hegiclient'sgiperistalsis.giThisgiisgiaginecessarygipartgiofgidetermininggithegipresencegiofgibow
elgisounds,giwhichgiaregiangiindicationgiofgithegistatusgiofgithegiclient'sgigastrointestinalgitract
.
Performgiagimanualgidigitalgiexaminationgiofgithegiclient'sgirectum
Theginursegishouldgiperformgiagimanualgidigitalgiexaminationgiofgithegiclient'sgirectumgitogid
eterminegiifgiimpactedgistoolgiisgipresent.giThisgiisgiagipartgiofgitheginecessarygievaluationgiof
githegistatusgiofgithegiclient'sgigastrointestinalgitract.
IncorrectgiAnswer:
Preparegithegiclientgiforgiagichestgix-raygiisgiincorrect.giAgichestgix-
raygiisgitypicallygiperformedgiforgiagiclientgiwhogihasgiangiimpairmentgiofgithegiuppergithoraxgi
orgilungs,ginotgithegiabdomen.giThegiclientgihasgialreadygireceivedgiangiabdominalgix-
ray;githerefore,giagichestgix-raygiisginotginecessary.
PreparegithegiclientgiforgiNGgitubegiplacementgiisgiincorrect.giTheginursegishouldginotgiprepa
regithegiclientgiforgiplacementgiofgiangiNGgitubegibecausegitheregiisginogiindicationgiorgiprescr
iptiongitogidogiso.giPlacementgiofgiangiNGgitubegiisgirequiredgiwhengitheregiisgiangiobstruction
giofgithegigastrointestinalgitractgiandgiperistalsisgiisgiabsent.
Aginursegiisgicaringgiforgiagiclientgiwhogiasksgiaboutgithegipurposegiofgiadvancegidirectives.gi
Whichgiofgithegifollowinggistatementsgishouldgitheginursegimake?
"Theygiallowgithegicourtgitogioverrulegiangiadultgiclient'sgirefusalgiofgimedicalgitreatment."
"Theygiindicategithegiformgiofgitreatmentgiagiclientgiisgiwillinggitogiacceptgiingithegieventgiofgiagi
seriousgiillness."
"Theygipermitgiagiclientgitogiwithholdgimedicalgiinformationgifromgihealthgicaregipersonnel."
"Theygiallowgihealthgicaregipersonnelgiingithegiemergencygidepartmentgitogistabilizegiagiclie
nt'sgicondition."gi-gianswer--CorrectgiAnswer:
"Theygiindicategithegiformgiofgitreatmentgiagiclientgiisgiwillinggitogiacceptgiingithegieventgiofgiagi
seriousgiillness."
Advancegidirectivesgiincludegiagilivinggiwill,giwhichgipermitsgiclientsgitogidirectgithegitreatme
ntgitheygiwillgireceivegiingithegieventgiofgiagimedicalgiemergencygiorgiseriousgiillness.
IncorrectgiAnswer:
"Theygiallowgithegicourtgitogioverrulegiangiadultgiclient'sgirefusalgiofgimedicalgitreatment."
, Agicourtgicangionlygioverrulegiangiadultgiclient'sgirefusalgiofgimedicalgitreatmentgiifgithegiclient
giisgilegallygiincompetent.
"Theygipermitgiagiclientgitogiwithholdgimedicalgiinformationgifromgihealthgicaregipersonnel."
ThegiAmericansgiwithgiDisabilitiesgiAct,ginotgiadvancegidirectives,giprotectsgithegiprivacygio
fgiagiclientgiwhogichoosesginotgitogidisclosegiagimedicalgidisability.
"Theygiallowgihealthgicaregipersonnelgiingithegiemergencygidepartmentgitogistabilizegiagiclie
nt'sgicondition."
ThegiEmergencygiMedicalgiTreatmentgiandgiActivegiLaborgiAct,ginotgiadvancegidirectives,gi
directsgiemergencygipersonnelgitogiprovidegiscreeninggiandgistabilizinggicaregibeforegidisc
harginggiorgitransferringgiclientsgitogianothergifacility.
Aginursegiisgicaringgiforgiagiclientgiwhogihasgiagiprescriptiongiforgi5giunitsgiofgiregulargiinsulingi
andgi10giunitsgiofgiNPHgiinsulingitogimixgitogethergiandgiadministergisubcutaneously.giDeter
minegithegicorrectgiordergiofgistepsgiforgithisgiprocedure.gi
Injectgi5giunitsgiofgiairgiintogithegibottlegiofgiregulargiinsulin
WithdrawgithegicorrectgidosegiofgiNPHgiinsulingifromgithegibottle
Injectgi10giunitsgiofgiairgiintogithegibottlegiofgiNPHgiinsulin
Withdrawgithegicorrectgidosegiofgiregulargiinsulingifromgithegibottlegi-gianswer--
CorrectgiAnswer:
Injectgi10giunitsgiofgiairgiintogithegibottlegiofgiNPHgiinsulin
Injectgi5giunitsgiofgiairgiintogithegibottlegiofgiregulargiinsulin
Withdrawgithegicorrectgidosegiofgiregulargiinsulingifromgithegibottle
WithdrawgithegicorrectgidosegiofgiNPHgiinsulingifromgithegibottle
TheginursegishouldgifirstgiinjectgiairgiintogithegivialgiofgiNPHgiinsulingiwithoutgitouchinggithegin
eedlegitogithegisolution.giNext,githeginursegishouldgiinjectgiairgiintogithegivialgiofgiregulargiinsuli
ngiandgiwithdrawgithegicorrectgiamountgiofgithegiregulargiinsulin.giFinally,githeginursegishould
giinsertgithegineedlegiintogithegiNPHgiinsulingivialgiandgiwithdrawgithegicorrectgiamountgiofgiN
PHgiinsulin.giTheginursegishouldgifollowgithesegistepsgitogipreventgicontaminatinggithegiregu
largiinsulingiwithgiNPHgiinsulin.
AginursegiisgiperforminggiagiRomberggitestgiduringgithegiphysicalgiassessmentgiofgiagiclient.gi
Whichgiofgithegifollowinggitechniquesgishouldgitheginursegiuse?
Touchgithegifacegiwithgiagicottongiball.
Applygiagivibratinggituninggiforkgitogithegiclient'sgiforehead.
Havegithegiclientgistandgiwithgitheirgiarmsgiatgitheirgisidesgiandgitheirgifeetgitogether.
Performgidirectgipercussiongiovergithegiareagiofgithegikidneys.gi-gianswer--CorrectgiAnswer:
Havegithegiclientgistandgiwithgitheirgiarmsgiatgitheirgisidesgiandgitheirgifeetgitogether.
AgiRomberggitestgihelpsgiidentifygialterationsgiingibalance.giTheginursegishouldgihavegithegic
lientgistandgiwithgitheirgiarmsgiatgitheirgisidesgiandgitheirgifeetgitogethergitogiobservegiforgiswa
yinggiandgiagilossgiofgibalance.
IncorrectgiAnswer:
Touchgithegifacegiwithgiagicottongiball.