ATI RN FUNDAMENTALS 2019
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. - ANSWER: 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 - ANSWER: 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. - ANSWER: 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." - ANSWER: 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 - ANSWER: 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. - ANSWER: 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:
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. - ANSWER: 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 - ANSWER: 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. - ANSWER: 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." - ANSWER: 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 - ANSWER: 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. - ANSWER: 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:
