ATI Proctored -- Fundamentals
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the
procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure
B. Help the client into a wheelchair before the transporter arrives
C. Ask if the client has any questions
D. Identify the client using two identifiers - (correct Answer) - D. Identify the client using two identifiers
The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are several
risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use
Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify
which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can
then proceed with the other options. This action is the priority action because it provides for the safety
of the client. It is a nursing responsibility to be certain that each client receives only what has been
prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of
the following actions should the nurse take to transfer the client from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher.
B. Instruct the client to raise his arms above his head.
C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed.
D. Log roll the client. - (correct Answer) - A. Lock the wheels on the bed and stretcher.
The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the
transfer. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. Logrolling is a
technique used to prevent injury when moving a client who requires immobilization of the neck, back, or
spine. It is not indicated for a client following abdominal surgery.
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who
might have a right ear infection. Which of the following routes should the nurse use to obtain the
, temperature?
A. Rectal
B. Tympanic
C. Oral
D. Temporal - (correct Answer) - D. Temporal
The temporal artery route, while not as accurate as the rectal route for obtaining a precise body
temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear
infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is
diaphoretic, but should avoid placing it over an area covered with hair.
The rectal route is very accurate for obtaining body temperature in young children; however, it should
not be used for clients who have diarrhea.
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the
client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft nontender abdomen, and
menses overdue by 2 days. Which of the following findings should be the nurse's priority?
A. Heart rate 105/min
B. Soft, nontender abdomen
C. Temperature
D. Overdue menses - (correct Answer) - C. Temperature
Elevated temperature is an emergent physiological need, which requires priority intervention by the
nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The
first level consists of physiological needs; the second level consists of safety and security needs; the third
level consists of love and belonging needs; the fourth level consists of personal achievement and self-
esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and
cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review
physiological needs first. The nurse should then address the client's needs by following the remaining
four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as
higher levels of the pyramid can compete with those at the lower levels, depending on the situation.
A nurse on a medical-surgical unit is washing her hands prior to assessing with a surgical procedure.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the
procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure
B. Help the client into a wheelchair before the transporter arrives
C. Ask if the client has any questions
D. Identify the client using two identifiers - (correct Answer) - D. Identify the client using two identifiers
The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are several
risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use
Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify
which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can
then proceed with the other options. This action is the priority action because it provides for the safety
of the client. It is a nursing responsibility to be certain that each client receives only what has been
prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of
the following actions should the nurse take to transfer the client from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher.
B. Instruct the client to raise his arms above his head.
C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed.
D. Log roll the client. - (correct Answer) - A. Lock the wheels on the bed and stretcher.
The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the
transfer. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. Logrolling is a
technique used to prevent injury when moving a client who requires immobilization of the neck, back, or
spine. It is not indicated for a client following abdominal surgery.
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who
might have a right ear infection. Which of the following routes should the nurse use to obtain the
, temperature?
A. Rectal
B. Tympanic
C. Oral
D. Temporal - (correct Answer) - D. Temporal
The temporal artery route, while not as accurate as the rectal route for obtaining a precise body
temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear
infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is
diaphoretic, but should avoid placing it over an area covered with hair.
The rectal route is very accurate for obtaining body temperature in young children; however, it should
not be used for clients who have diarrhea.
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the
client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft nontender abdomen, and
menses overdue by 2 days. Which of the following findings should be the nurse's priority?
A. Heart rate 105/min
B. Soft, nontender abdomen
C. Temperature
D. Overdue menses - (correct Answer) - C. Temperature
Elevated temperature is an emergent physiological need, which requires priority intervention by the
nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The
first level consists of physiological needs; the second level consists of safety and security needs; the third
level consists of love and belonging needs; the fourth level consists of personal achievement and self-
esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and
cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review
physiological needs first. The nurse should then address the client's needs by following the remaining
four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as
higher levels of the pyramid can compete with those at the lower levels, depending on the situation.
A nurse on a medical-surgical unit is washing her hands prior to assessing with a surgical procedure.
