ATI NUR265 Exam Questions and
Answers
Question 1: A home health nurse is assisting a client in planning care for a
family member who has Alzheimer's disease. Which of the following
instructions should the nurse include?
A) Restrict the client's access to the home to prevent wandering
B) Review the daily schedule with the client every morning
C) Avoid discussing the client's past to prevent confusion
D) Keep the client sedated during the day for safety
ANSWER: B - Review the daily schedule with the client every morning
Question 2: A nurse in a long-term care facility is caring for a client who has
dementia. Which of the following actions should the nurse take?
A) Keep the client isolated to maintain calm
B) Provide finger foods at meal time
C) Use complex verbal instructions for all tasks
D) Encourage the client to eat large meals independently
ANSWER: B - Provide finger foods at meal time
Question 3: A nurse in an emergency department is assessing a client who is
overusing prescribed diuretics and has a sodium level of 127. Which of the
following lab findings should the nurse expect?
A) High urine specific gravity with elevated osmolality
B) Low urine specific gravity
C) Normal urine specific gravity with high sodium
D) High urine specific gravity with low osmolality
ANSWER: B - Low urine specific gravity
Question 4: A nurse is assessing a client for fluid volume deficit following
lumbar spinal surgery. Which of the following findings indicates the client is at
risk for fluid volume deficit?
,A) Urine output of 50 mL per hour
B) Surgical drain output of 300 mL during an eight-hour shift
C) Blood pressure increase of 10 mm Hg
D) Skin turgor that returns immediately
ANSWER: B - Surgical drain output of 300 mL during an eight-hour shift
Question 5: A nurse is assessing a client who is suspected of having
appendicitis. Which of the following manifestations should the nurse expect?
(Select all that apply)
A) Elevated WBC count, rebound tenderness, anorexia
B) Decreased WBC count, hyperactive bowel sounds
C) Hyperthermia, increased appetite
D) Tachycardia, diarrhea
ANSWER: A - Elevated WBC count, rebound tenderness, anorexia
Question 6: A nurse is assessing a client who has a central venous catheter
with IV fluids infusing. The client suddenly develops shortness of breath and
the IV tubing and needleless connector device are disconnected. Which action
should the nurse take first?
A) Clamp the catheter proximally at the skin
B) Close the pinch clamp on the CVC
C) Place the client in Trendelenburg position
D) Notify the provider immediately
ANSWER: B - Close the pinch clamp on the CVC
Question 7: A nurse is assessing a client who has a chest tube connected to a
closed water seal drainage system. Which of the following findings should the
nurse report to the provider?
A) Gentle bubbling during expiration
B) Constant bubbling in the water seal chamber
C) Fluctuation of fluid in the water seal chamber
D) Slight hissing sound from the chamber
, ANSWER: B - Constant bubbling in the water seal chamber (indicates air leak)
Question 8: A nurse is assessing a client with a history of type 2 diabetes
mellitus. Which of the following findings indicates a microvascular
complication?
A) Coronary artery disease
B) Peripheral arterial disease
C) Retinopathy
D) Cerebrovascular accident
ANSWER: C - Retinopathy
Question 9: A nurse is assessing a client with a new diagnosis of diabetes
mellitus. Which of the following findings is a manifestation of hyperglycemia?
A) Bradycardia and decreased appetite
B) Hypotension and lethargy
C) Increased thirst
D) Tremors and diaphoresis
ANSWER: C - Increased thirst
Question 10: A nurse is assessing a client with a new diagnosis of pericarditis.
Which of the following findings indicates cardiac tamponade?
A) Persistent friction rub on auscultation
B) Paradoxical pulse
C) Elevated ST segments on ECG
D) Chest pain relieved by leaning forward
ANSWER: B - Paradoxical pulse
Question 11: A nurse is assessing a client with an exacerbation of diverticular
disease. In which of the following quadrants should the nurse anticipate the
client experiencing abdominal pain?
A) Right upper quadrant
B) Right lower quadrant
C) Left lower quadrant
Answers
Question 1: A home health nurse is assisting a client in planning care for a
family member who has Alzheimer's disease. Which of the following
instructions should the nurse include?
A) Restrict the client's access to the home to prevent wandering
B) Review the daily schedule with the client every morning
C) Avoid discussing the client's past to prevent confusion
D) Keep the client sedated during the day for safety
ANSWER: B - Review the daily schedule with the client every morning
Question 2: A nurse in a long-term care facility is caring for a client who has
dementia. Which of the following actions should the nurse take?
A) Keep the client isolated to maintain calm
B) Provide finger foods at meal time
C) Use complex verbal instructions for all tasks
D) Encourage the client to eat large meals independently
ANSWER: B - Provide finger foods at meal time
Question 3: A nurse in an emergency department is assessing a client who is
overusing prescribed diuretics and has a sodium level of 127. Which of the
following lab findings should the nurse expect?
A) High urine specific gravity with elevated osmolality
B) Low urine specific gravity
C) Normal urine specific gravity with high sodium
D) High urine specific gravity with low osmolality
ANSWER: B - Low urine specific gravity
Question 4: A nurse is assessing a client for fluid volume deficit following
lumbar spinal surgery. Which of the following findings indicates the client is at
risk for fluid volume deficit?
,A) Urine output of 50 mL per hour
B) Surgical drain output of 300 mL during an eight-hour shift
C) Blood pressure increase of 10 mm Hg
D) Skin turgor that returns immediately
ANSWER: B - Surgical drain output of 300 mL during an eight-hour shift
Question 5: A nurse is assessing a client who is suspected of having
appendicitis. Which of the following manifestations should the nurse expect?
(Select all that apply)
A) Elevated WBC count, rebound tenderness, anorexia
B) Decreased WBC count, hyperactive bowel sounds
C) Hyperthermia, increased appetite
D) Tachycardia, diarrhea
ANSWER: A - Elevated WBC count, rebound tenderness, anorexia
Question 6: A nurse is assessing a client who has a central venous catheter
with IV fluids infusing. The client suddenly develops shortness of breath and
the IV tubing and needleless connector device are disconnected. Which action
should the nurse take first?
A) Clamp the catheter proximally at the skin
B) Close the pinch clamp on the CVC
C) Place the client in Trendelenburg position
D) Notify the provider immediately
ANSWER: B - Close the pinch clamp on the CVC
Question 7: A nurse is assessing a client who has a chest tube connected to a
closed water seal drainage system. Which of the following findings should the
nurse report to the provider?
A) Gentle bubbling during expiration
B) Constant bubbling in the water seal chamber
C) Fluctuation of fluid in the water seal chamber
D) Slight hissing sound from the chamber
, ANSWER: B - Constant bubbling in the water seal chamber (indicates air leak)
Question 8: A nurse is assessing a client with a history of type 2 diabetes
mellitus. Which of the following findings indicates a microvascular
complication?
A) Coronary artery disease
B) Peripheral arterial disease
C) Retinopathy
D) Cerebrovascular accident
ANSWER: C - Retinopathy
Question 9: A nurse is assessing a client with a new diagnosis of diabetes
mellitus. Which of the following findings is a manifestation of hyperglycemia?
A) Bradycardia and decreased appetite
B) Hypotension and lethargy
C) Increased thirst
D) Tremors and diaphoresis
ANSWER: C - Increased thirst
Question 10: A nurse is assessing a client with a new diagnosis of pericarditis.
Which of the following findings indicates cardiac tamponade?
A) Persistent friction rub on auscultation
B) Paradoxical pulse
C) Elevated ST segments on ECG
D) Chest pain relieved by leaning forward
ANSWER: B - Paradoxical pulse
Question 11: A nurse is assessing a client with an exacerbation of diverticular
disease. In which of the following quadrants should the nurse anticipate the
client experiencing abdominal pain?
A) Right upper quadrant
B) Right lower quadrant
C) Left lower quadrant
