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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 clientJthe nurse should assess is followed by .
Client 1: ClientJis 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: Cl
ientJis 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcuta
neous administered as prescribed.Client 4: ClientJis admitted with a new diagnosis of hear
tJfailure.Client 5: ClientJhas a stage 2 pressure injury on the leftJheel.Client 6: ClientJis adm
itted with a new diagnosis of diabetes mellitus. -
CORRECT ANSWERS Correct Answer (1):
Client 3
When using the airway, breathing, circulation approach to clientJcare, the nurse should det
ermine thatJthis client is the priority clientJto assess. The client has an oxygen saturation th
at is less than the expected reference range, which is an indication of hypoxia.
CorrectJAnswer (2):
Client 4
When using the airway, breathing, circulation approach to clientJcare, the nurse should det
ermine thatJthis client is the nextJpriority clientJto assess. The client has a potassium level t
hat is less than the expected reference range, which places the client atJrisk for dysrhythm
ias.
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 infl
ammation. However, there is another clientJthe nurse should assess first.
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Client 2 is incorrect. The nurse should assess this client because the client's cholesterol le
vel is greater than the expected reference range, which places them atJriskJfor coronary he
art 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 l
ess than the expected reference range, which places them at risk for delayed wound heali
ng. However, this client is notJthe next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated hemo
globin level is greater than the expected reference range, which indicates poor diabeticJco
ntrol. However, this client is notJthe 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
HeartJrate - CORRECT ANSWERS Correct Answer:
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumonia. De
creased 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%, indi
cating 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 infecti
on, and requires follow-up by the nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference ra
nge and does notJrequire follow-up by the nurse.
HeartJrate is incorrect. The client's heart rate is within the expected reference range of 60 t
o 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 pai
n.
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 chestJx-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 rightJknee flexed prior to administering an enema. Because the prov
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ider prescribed a cleansing enema for the client, the nurse should prepare the client for th
e procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the client as a result of the provider's p
rescription. AJcleansing enema is intended to assist with bowel elimination and remove an
y 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 partJof 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 cl
ient's gastrointestinal tract.
Incorrect Answer:
Prepare the client for a chestJx-ray is incorrect. A chestJx-
ray is typically performed for a client who has an impairment of the upper thoraxJor lungs,
not the abdomen. The client hasJalready received an abdominal x-
ray; therefore, a chestJx-ray is not necessary.
Prepare the client for NG tube placementJis incorrect. The nurse should not prepare the cli
ent for placementJof an NG tube because there is no indication or prescription to do so. Pl
acement of an NG tube is required when there is an obstruction of the gastrointestinal trac
tJand peristalsis is absent.
A nurse is caring for a client who asks aboutJthe purpose of advance directives. Which of t
he 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 clientJthe nurse should assess is followed by .
Client 1: ClientJis 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: Cl
ientJis 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcuta
neous administered as prescribed.Client 4: ClientJis admitted with a new diagnosis of hear
tJfailure.Client 5: ClientJhas a stage 2 pressure injury on the leftJheel.Client 6: ClientJis adm
itted with a new diagnosis of diabetes mellitus. -
CORRECT ANSWERS Correct Answer (1):
Client 3
When using the airway, breathing, circulation approach to clientJcare, the nurse should det
ermine thatJthis client is the priority clientJto assess. The client has an oxygen saturation th
at is less than the expected reference range, which is an indication of hypoxia.
CorrectJAnswer (2):
Client 4
When using the airway, breathing, circulation approach to clientJcare, the nurse should det
ermine thatJthis client is the nextJpriority clientJto assess. The client has a potassium level t
hat is less than the expected reference range, which places the client atJrisk for dysrhythm
ias.
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 infl
ammation. However, there is another clientJthe nurse should assess first.
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and Answers allAnswers100%Correctly/VerifiedAnswers
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Client 2 is incorrect. The nurse should assess this client because the client's cholesterol le
vel is greater than the expected reference range, which places them atJriskJfor coronary he
art 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 l
ess than the expected reference range, which places them at risk for delayed wound heali
ng. However, this client is notJthe next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated hemo
globin level is greater than the expected reference range, which indicates poor diabeticJco
ntrol. However, this client is notJthe 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
HeartJrate - CORRECT ANSWERS Correct Answer:
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumonia. De
creased 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%, indi
cating 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 infecti
on, and requires follow-up by the nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference ra
nge and does notJrequire follow-up by the nurse.
HeartJrate is incorrect. The client's heart rate is within the expected reference range of 60 t
o 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 pai
n.
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 chestJx-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 rightJknee flexed prior to administering an enema. Because the prov
, ATI RN FundamentalsOnlinePractice2025/2026BQuestions
and Answers allAnswers100%Correctly/VerifiedAnswers
BrandNewRATEDA+
ider prescribed a cleansing enema for the client, the nurse should prepare the client for th
e procedure.
Administer a cleansing enema
The nurse should administer a cleansing enema for the client as a result of the provider's p
rescription. AJcleansing enema is intended to assist with bowel elimination and remove an
y 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 partJof 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 cl
ient's gastrointestinal tract.
Incorrect Answer:
Prepare the client for a chestJx-ray is incorrect. A chestJx-
ray is typically performed for a client who has an impairment of the upper thoraxJor lungs,
not the abdomen. The client hasJalready received an abdominal x-
ray; therefore, a chestJx-ray is not necessary.
Prepare the client for NG tube placementJis incorrect. The nurse should not prepare the cli
ent for placementJof an NG tube because there is no indication or prescription to do so. Pl
acement of an NG tube is required when there is an obstruction of the gastrointestinal trac
tJand peristalsis is absent.
A nurse is caring for a client who asks aboutJthe purpose of advance directives. Which of t
he following statements should the nurse make?
