ATI Fundamentals Test Exam 2 2024 practice questions and answers (verified).

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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.