ATI Review ACTUAL EXAM (250 QUESTIONS AND CORRECT
ANSWERS) 2026 LATEST GRADED A+
A nurse is assessing a client who has been on bed rest for the past month. Which of the following
findings should the nurse identify as an indication that the client has developed thrombophlebitis? -
CORRECT ANSWER-Complications of Immobility
-swelling, redness and tenderness in calf muscle may indicate thrombophlebitis
- bladder distention indicates urinary retention due to loss of muscle tone and detrusor muscles in
bladder
- hypoventilation, hypoxia, hypercapnia = respiratory acidosis (low pH, CO2 above 45)
- decreased peristalsis and intestinal motility = decreased bowel sounds may indicate constipation
- decreased cardiac output, decreased BP, and tachycardia
- hypercalcemia as bones demineralize from a lack of weight bearing exercise and excess calcium
is deposited into joints causing stiffness and pain
A nurse is caring for a PT who requires 24-hour urine collection. Which of the following statements
by the client indicates an understanding of the teaching? - CORRECT ANSWER-- collect urine that is
free of feces
- place any urine in container immediately and keep it on ice or in a refrigerator.
- discard first voiding and save all subsequent voidings.
- collection takes place over 24 hrs with no specified amoun
A nurse is teaching an older adult PT who is at risk for osteoporosis about beginning a program of
regular physical activity. Which of the following types of activity should the nurse recommend? -
CORRECT ANSWER-Regular Physical Exercise for Older Adult
- walking briskly
- weight bearing exercises to maintain bone mass
- cycling and isometric exercises have no weight bearing advantages and do not prevent
osteoporosis
- high impact aerobics can injure bones with density loss therefore they are not recommended
for osteoporosis patients
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should
identify that which of the following findings requires further intervention? - CORRECT ANSWER--
,using trapeze bar to assist with repositioning and transfer helps to avoid friction and shearing caused
by sliding up and down in bed which reduces the risk of pressure ulcers
- consume balanced diet with adequate fluid intake (2-3 L/day)
- less than 3 bowel movements per week indicates constipation and the need for intervention
-pulse strength of +2 on lower extremities is norma
Risks for Skin BReakdown
- report any signs of erythema on pressure points
- High Fowler's position places additional pressure on sacrum and heels
- massage can cause capillary breakdown of subcutaneous tissue
A nurse is caring for a PT who requires bed rest and has a prescription for antiembolic
stockings. Which of the following actions should the nurse take?
- CORRECT ANSWER-- turn stocking inside out up to heel before applying
- apply stockings in the morning before client gets out of bed
- slide top of stocking up over calf all at once to lesson constrictive wrinkles
- ensure there are no creases or wrinkles
- if stocking is too long, apply another size stocking
- remove stockings once per shift to assess circulation and skin integrity
- wear stockings while sitting in chair to promote venous return and avoid crossing legs
A nurse is administering IV fluids to an older adult client. The nurse should perform which pirority
assessment to monitor for adverse effects? –
CORRECT ANSWER-Adverse Effects of IV Fluids in Older Adults (fluid overload)
- use ABC or airway, breathing, circulation method so ausculatate the lungs to see if crackles,
dyspnea, or SOB are present then assess BP to evaluate hemodynamic stability, and measure
urine output to monitor renal function, then measure serum electrolytes (sodium) to guide
planning of interventions
A nurse is assessing a clients readiness to learn about insulin administration. Which of the following
statements should the nurse identify as an indication that the PT is ready to learn? –
CORRECT ANSWER-Readiness to learn
- verbalize best time to learn
, - if client verbalizes the need for tools to learn and comprehend info, or redirects the nurse to
teach someone else, or thinks its something he or she might not need to know, this shows
reluctance and not ready to learn
A nurse manager is overseeing care on a unit. Which of the following situations should the nurse
manager identify as a violation of HIPPA guidelines?
- CORRECT ANSWER-A. a nurse caring for a client reviews the medical chart with nursing
student who is working with the nurse
B. a nurse asks a nurse from another unit to assist with documentation
C. A nurse who is caring for a PT returns a call to the PT's durable power of attorney for health care
designee to discuss the PT's care
D. a nurse discusses a client's status with the physical therapist that is caring for the PT at bedside
Any health care professional directly caring for a client has access to medical information; therefore,
this is not a violation of HIPAA guidelines.
Only health care professionals directly caring for a client may access medical information; therefore,
this is a violation of HIPAA guidelines.
The person the durable power of attorney for health care designates has a legal right to information
about the client's care; therefore, this is not a violation of HIPAA guidelines.
A nurse is performing Romberg's test during a physical assessment of a PT. Which of the following
techniques should the nurse use? –
CORRECT ANSWER-A. touch the face with a cotton ball
B. apply a vibrating tuning fork to the clients forhead
C. have the client stand iwth arsm at side and feet together
D. perform direct percussion over the area of the kidneys
The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain
across the client's face to test cranial nerve V, the trigeminal nerve.
The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to
identify sound lateralization when assessing hearing.
Romberg's test helps identify alterations in balance. The nurse should have the client stand with her
arms at her sides and her feet together to observe her for swaying and a loss of balance.
The nurse should perform direct percussion over the area of the kidneys to evaluate them for
inflammation.
, A nurse is planning an education session for an older adult client who has just learned that she has
Type 2 Diabetes Mellitus. Which of the following strategies should the nurse plan to use with this
client? - CORRECT ANSWER-A. allow extra time for the PT to respond to questions
B. expect the client to have difficulty understanding information
C. avoid references to the PT's past experiences
D keep the learning session private and one-on-one
Older adult clients often process information at a slower rate than younger clients; therefore, the
nurse should plan for extra time to allow the client to ask questions and absorb the information.
Cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse
should assess the client's cognition and ability to learn, teach accordingly, and verify understanding.
The nurse should explore the client's past experiences and use them to establish connections to new
knowledge.
It is helpful when working with older adult clients to invite another household member to the
teaching session so that person can help reinforce new information later. The nurse should also
honor the client's preference for either one-on-one or group settings..
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a PT. Which of the
following actions should the nurse take? - CORRECT ANSWER-- shake the liquid medication to make
sure its mixed
-place client in High-Fowler's to reduce the risk of aspiration
- do not transfer prepackaged liquid medication to medicine cup or measuring device as this
increases the risk of altering premeasured dose
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the
following actions should the nurse take first? - CORRECT ANSWER-A. check the client for injuries
B. move haxardous objects away from the PT
C. notify the provider
D. ask the client to describe how she felt prior to the fall
The priority action the nurse should take when using the nursing process is to assess the client for
injuries.
Secondary actions include moving hazardous objects away to prevent further injury, notifying the
provider to inform him of the fall, and determining facts that surround the fall is important to help
prevent subsequent falls;
ANSWERS) 2026 LATEST GRADED A+
A nurse is assessing a client who has been on bed rest for the past month. Which of the following
findings should the nurse identify as an indication that the client has developed thrombophlebitis? -
CORRECT ANSWER-Complications of Immobility
-swelling, redness and tenderness in calf muscle may indicate thrombophlebitis
- bladder distention indicates urinary retention due to loss of muscle tone and detrusor muscles in
bladder
- hypoventilation, hypoxia, hypercapnia = respiratory acidosis (low pH, CO2 above 45)
- decreased peristalsis and intestinal motility = decreased bowel sounds may indicate constipation
- decreased cardiac output, decreased BP, and tachycardia
- hypercalcemia as bones demineralize from a lack of weight bearing exercise and excess calcium
is deposited into joints causing stiffness and pain
A nurse is caring for a PT who requires 24-hour urine collection. Which of the following statements
by the client indicates an understanding of the teaching? - CORRECT ANSWER-- collect urine that is
free of feces
- place any urine in container immediately and keep it on ice or in a refrigerator.
- discard first voiding and save all subsequent voidings.
- collection takes place over 24 hrs with no specified amoun
A nurse is teaching an older adult PT who is at risk for osteoporosis about beginning a program of
regular physical activity. Which of the following types of activity should the nurse recommend? -
CORRECT ANSWER-Regular Physical Exercise for Older Adult
- walking briskly
- weight bearing exercises to maintain bone mass
- cycling and isometric exercises have no weight bearing advantages and do not prevent
osteoporosis
- high impact aerobics can injure bones with density loss therefore they are not recommended
for osteoporosis patients
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should
identify that which of the following findings requires further intervention? - CORRECT ANSWER--
,using trapeze bar to assist with repositioning and transfer helps to avoid friction and shearing caused
by sliding up and down in bed which reduces the risk of pressure ulcers
- consume balanced diet with adequate fluid intake (2-3 L/day)
- less than 3 bowel movements per week indicates constipation and the need for intervention
-pulse strength of +2 on lower extremities is norma
Risks for Skin BReakdown
- report any signs of erythema on pressure points
- High Fowler's position places additional pressure on sacrum and heels
- massage can cause capillary breakdown of subcutaneous tissue
A nurse is caring for a PT who requires bed rest and has a prescription for antiembolic
stockings. Which of the following actions should the nurse take?
- CORRECT ANSWER-- turn stocking inside out up to heel before applying
- apply stockings in the morning before client gets out of bed
- slide top of stocking up over calf all at once to lesson constrictive wrinkles
- ensure there are no creases or wrinkles
- if stocking is too long, apply another size stocking
- remove stockings once per shift to assess circulation and skin integrity
- wear stockings while sitting in chair to promote venous return and avoid crossing legs
A nurse is administering IV fluids to an older adult client. The nurse should perform which pirority
assessment to monitor for adverse effects? –
CORRECT ANSWER-Adverse Effects of IV Fluids in Older Adults (fluid overload)
- use ABC or airway, breathing, circulation method so ausculatate the lungs to see if crackles,
dyspnea, or SOB are present then assess BP to evaluate hemodynamic stability, and measure
urine output to monitor renal function, then measure serum electrolytes (sodium) to guide
planning of interventions
A nurse is assessing a clients readiness to learn about insulin administration. Which of the following
statements should the nurse identify as an indication that the PT is ready to learn? –
CORRECT ANSWER-Readiness to learn
- verbalize best time to learn
, - if client verbalizes the need for tools to learn and comprehend info, or redirects the nurse to
teach someone else, or thinks its something he or she might not need to know, this shows
reluctance and not ready to learn
A nurse manager is overseeing care on a unit. Which of the following situations should the nurse
manager identify as a violation of HIPPA guidelines?
- CORRECT ANSWER-A. a nurse caring for a client reviews the medical chart with nursing
student who is working with the nurse
B. a nurse asks a nurse from another unit to assist with documentation
C. A nurse who is caring for a PT returns a call to the PT's durable power of attorney for health care
designee to discuss the PT's care
D. a nurse discusses a client's status with the physical therapist that is caring for the PT at bedside
Any health care professional directly caring for a client has access to medical information; therefore,
this is not a violation of HIPAA guidelines.
Only health care professionals directly caring for a client may access medical information; therefore,
this is a violation of HIPAA guidelines.
The person the durable power of attorney for health care designates has a legal right to information
about the client's care; therefore, this is not a violation of HIPAA guidelines.
A nurse is performing Romberg's test during a physical assessment of a PT. Which of the following
techniques should the nurse use? –
CORRECT ANSWER-A. touch the face with a cotton ball
B. apply a vibrating tuning fork to the clients forhead
C. have the client stand iwth arsm at side and feet together
D. perform direct percussion over the area of the kidneys
The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain
across the client's face to test cranial nerve V, the trigeminal nerve.
The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to
identify sound lateralization when assessing hearing.
Romberg's test helps identify alterations in balance. The nurse should have the client stand with her
arms at her sides and her feet together to observe her for swaying and a loss of balance.
The nurse should perform direct percussion over the area of the kidneys to evaluate them for
inflammation.
, A nurse is planning an education session for an older adult client who has just learned that she has
Type 2 Diabetes Mellitus. Which of the following strategies should the nurse plan to use with this
client? - CORRECT ANSWER-A. allow extra time for the PT to respond to questions
B. expect the client to have difficulty understanding information
C. avoid references to the PT's past experiences
D keep the learning session private and one-on-one
Older adult clients often process information at a slower rate than younger clients; therefore, the
nurse should plan for extra time to allow the client to ask questions and absorb the information.
Cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse
should assess the client's cognition and ability to learn, teach accordingly, and verify understanding.
The nurse should explore the client's past experiences and use them to establish connections to new
knowledge.
It is helpful when working with older adult clients to invite another household member to the
teaching session so that person can help reinforce new information later. The nurse should also
honor the client's preference for either one-on-one or group settings..
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a PT. Which of the
following actions should the nurse take? - CORRECT ANSWER-- shake the liquid medication to make
sure its mixed
-place client in High-Fowler's to reduce the risk of aspiration
- do not transfer prepackaged liquid medication to medicine cup or measuring device as this
increases the risk of altering premeasured dose
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the
following actions should the nurse take first? - CORRECT ANSWER-A. check the client for injuries
B. move haxardous objects away from the PT
C. notify the provider
D. ask the client to describe how she felt prior to the fall
The priority action the nurse should take when using the nursing process is to assess the client for
injuries.
Secondary actions include moving hazardous objects away to prevent further injury, notifying the
provider to inform him of the fall, and determining facts that surround the fall is important to help
prevent subsequent falls;
