Terms in this set (60)
CAPSTONE FUNDAMENTALS RN ATI VERSION D
NEWEST 2024 ACTUAL EXAM COMPLETE 250
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
, 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
A nurse in a medical-
saturation that is less than the expected reference range,
surgical unit is caring for six
which is an indication of hypoxia.
clients.
Correct Answer (2):
Complete the following
Client 4
sentence by using the list of
When using the airway, breathing, circulation approach
options.
to client care, the nurse should determine that this client
is the next priority client to assess. The client has a
The first client the nurse
potassium level that is less than the expected reference
should assess is _____
range, which places the client at risk for dysrhythmias.
followed by _____.
Incorrect Answers (1):
Client 1: Client is admitted
Client 1 is incorrect. The nurse should assess this client
with a new diagnosis of
because the client's C-reactive protein is greater than
rheumatoid arthritis.Client 2:
the expected reference range, which is an indication of
Client has a history of
inflammation. However, there is another client the nurse
hyperlipidemia. Atorvastatin
should assess first.
20 mg PO administered as
prescribed.Client 3: Client is
Client 2 is incorrect. The nurse should assess this client
1 day postoperative.
because the client's cholesterol level is greater than the
Reports pain as 8 on a scale
expected reference range, which places them at risk for
of 0 to 10. Morphine 5 mg
coronary heart disease. However, there is another client
subcutaneous administered
the nurse should assess first.
as prescribed.Client 4:
Client is admitted with a
Incorrect Answers (2):
new diagnosis of heart
Client 5 is incorrect. The nurse should assess this client
failure.Client 5: Client has a
because their prealbumin level is less than the expected
stage 2 pressure injury on
reference range, which places them at risk for delayed
the left heel.Client 6: Client
wound healing. However, this client is not the next
is admitted with a new
priority client to assess.
diagnosis of diabetes
mellitus.
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.
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.
A nurse is caring for a client Oxygen Saturation
who has COPD. The client's oxygen saturation is below the expected
reference range of 95% to 100%, indicating hypoxia, and
Select the 3 findings that requires follow-up by the nurse.
require follow-up.
Temperature
Breath sounds The client's temperature is greater than the expected
Blood pressure reference range, indicating an infection, and requires
Oxygen saturation follow-up by the nurse.
Temperature
Heart rate 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.
, 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.
A nurse in the emergency
department (ED) is caring Administer a cleansing enema
for a client who reports The nurse should administer a cleansing enema for the
abdominal pain. client as a result of the provider's prescription. A
cleansing enema is intended to assist with bowel
Based on the client's clinical elimination and remove any impacted fecal matter
findings, which of the indicated by the abdominal x-ray.
following actions should the
nurse take? Select all that Auscultate the client's bowel sounds
apply. The nurse should auscultate the client's bowel sounds to
determine the status of the client's peristalsis. This is a
Assist the client to a left necessary part of determining the presence of bowel
side-lying position with the sounds, which are an indication of the status of the
right knee flexed. client's gastrointestinal tract.
Prepare the client for a
chest x-ray. Perform a manual digital examination of the client's
Administer a cleansing rectum
enema. The nurse should perform a manual digital examination
Auscultate the client's of the client's rectum to determine if impacted stool is
bowel sounds. present. This is a part of the necessary evaluation of the
Perform a manual digital status of the client's gastrointestinal tract.
examination of the client's
rectum. Incorrect Answer:
Administer oxycodone Prepare the client for a chest x-ray is incorrect. A chest x-
extended-release tablets. ray is typically performed for a client who has an
Prepare the client for NG impairment of the upper thorax or lungs, not the
tube placement. abdomen. The client has already received an abdominal
x-ray; therefore, a chest x-ray is not necessary.