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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 h
as 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 diagno
sis of heart failure.Client 5: ClientAhas 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 clientAis the priority client to assess. The client has an oxygen saturat
ion 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 clientAis the nextApriority client to assess. The client has a potassium
level that is less than the expected reference range, which places the client at risk for dy
srhythmias.
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 i
nflammation. However, there is another clientAthe nurse should assess first.
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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 Arisk for corona
ry 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 i
s 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 hem
oglobin level is greater than the expected reference range, which indicates poor diabetic
control. However, this client is not the next priority clientAto assess.
A nurse is caring for a clientAwho 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. D
ecreased 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%, i
ndicating 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 infe
ction, 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 6
0 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 tak
e? Select all that apply.
Assist the client to a left side-lying position with the right knee flexed.
Prepare the clientAfor 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 clientAfor 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 clientAin a left side-
lying position with the right knee flexed prior to administering an enema. Because the pr
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ovider prescribed a cleansing enema for the client, the nurse should prepare the client f
or the procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the clientAas a result of the provider'
s prescription. AAcleansing enema is intended to assist with bowel elimination and remo
ve 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 clie
nt's peristalsis. This is a necessary part of determining the presence of bowel sounds, w
hich 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 determi
ne if impacted stool is present. This is a partAof the necessary evaluation of the status of
the client's gastrointestinal tract.
Incorrect Answer:
Prepare the clientAfor 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 lung
s, not the abdomen. The client has already received an abdominal x-
ray; therefore, a chest x-ray is not necessary.
Prepare the clientAfor NG tube placementAis incorrect. The nurse should notAprepare the
client for placement of an NG tube because there is no indication or prescription to do s
o. Placement of an NG tube is required when there is an obstruction of the gastrointesti
nal tract and peristalsis is absent.
A nurse is caring for a clientAwho asks about the purpose of advance directives. Which o
f the following statements should the nurse make?
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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 h
as 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 diagno
sis of heart failure.Client 5: ClientAhas 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 clientAis the priority client to assess. The client has an oxygen saturat
ion 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 clientAis the nextApriority client to assess. The client has a potassium
level that is less than the expected reference range, which places the client at risk for dy
srhythmias.
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 i
nflammation. However, there is another clientAthe nurse should assess first.
,ATI RN FundamentalsOnlinePractice2025/2026BQuestions
and Answers allAnswers100%Correctly/VerifiedAnswers
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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 Arisk for corona
ry 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 i
s 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 hem
oglobin level is greater than the expected reference range, which indicates poor diabetic
control. However, this client is not the next priority clientAto assess.
A nurse is caring for a clientAwho 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. D
ecreased 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%, i
ndicating hypoxia, and requires follow-up by the nurse.
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and Answers allAnswers100%Correctly/VerifiedAnswers
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Temperature
The client's temperature is greater than the expected reference range, indicating an infe
ction, 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 6
0 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 tak
e? Select all that apply.
Assist the client to a left side-lying position with the right knee flexed.
Prepare the clientAfor 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 clientAfor 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 clientAin a left side-
lying position with the right knee flexed prior to administering an enema. Because the pr
, ATI RN FundamentalsOnlinePractice2025/2026BQuestions
and Answers allAnswers100%Correctly/VerifiedAnswers
BrandNewRATEDA+
ovider prescribed a cleansing enema for the client, the nurse should prepare the client f
or the procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the clientAas a result of the provider'
s prescription. AAcleansing enema is intended to assist with bowel elimination and remo
ve 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 clie
nt's peristalsis. This is a necessary part of determining the presence of bowel sounds, w
hich 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 determi
ne if impacted stool is present. This is a partAof the necessary evaluation of the status of
the client's gastrointestinal tract.
Incorrect Answer:
Prepare the clientAfor 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 lung
s, not the abdomen. The client has already received an abdominal x-
ray; therefore, a chest x-ray is not necessary.
Prepare the clientAfor NG tube placementAis incorrect. The nurse should notAprepare the
client for placement of an NG tube because there is no indication or prescription to do s
o. Placement of an NG tube is required when there is an obstruction of the gastrointesti
nal tract and peristalsis is absent.
A nurse is caring for a clientAwho asks about the purpose of advance directives. Which o
f the following statements should the nurse make?
