1. 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 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
, ATI RN Fundamentals Online Practice 2023 B
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.
2. 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.
, ATI RN Fundamentals Online Practice 2023 B
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.
3. 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.
Incorrect Answer:
, ATI RN Fundamentals Online Practice 2023 B
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.
4. 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."
"They indicate the form of treatment a client is willing to accept in the event
of a serious illness."
"They permit a client to withhold medical information from health care
personnel."
"They allow health care personnel in the emergency department to stabilize a
client's condition.": Correct Answer:
"They indicate the form of treatment a client is willing to accept in the event of a
serious illness."
Advance directives include a living will, which permits clients to direct the
treatment they will receive in the event of a medical emergency or serious illness.
Incorrect Answer:
"They allow the court to overrule an adult client's refusal of medical treatment." A
court can only overrule an adult client's refusal of medical treatment if the client
is legally incompetent.
"They permit a client to withhold medical information from health care personnel."
The Americans with Disabilities Act, not advance directives, protects the privacy of
a client who chooses not to disclose a medical disability.
"They allow health care personnel in the emergency department to stabilize a
client's condition."
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