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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 ANSWERS 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.
,ATI RN Fundamentals Online Practice 2025/2026 B
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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 ANSWERS 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.
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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 ANSWERS 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.
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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."
Questions and Answers all Answers 100%Correctly/Verified
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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 ANSWERS 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.
,ATI RN Fundamentals Online Practice 2025/2026 B
Questions and Answers all Answers 100%Correctly/Verified
Answers Brand New RATED A+
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 ANSWERS 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.
,ATI RN Fundamentals Online Practice 2025/2026 B
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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 ANSWERS 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.
, ATI RN Fundamentals Online Practice 2025/2026 B
Questions and Answers all Answers 100%Correctly/Verified
Answers Brand New RATED A+
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."
