2026 ATI PROCTORED ACTUAL EXAM LATEST VERSION
2026-2027 100 QUESTION AND CORRECT ANSWERS
WITH RATIONALES RATED A GRADE.
Question
A nurse is providing care for an adult client who has recently become disoriented
and confused. When reviewing the client's most recent laboratory results, which
of the following findings should the nurse identify as a potential contributing
factor to the client's altered mental status?
a. Serum potassium level of 5.2 mEq/L
b. Serum calcium level of 10.8 mg/dL
c. Serum sodium level of 123 mEq/L
d. Serum glucose level of 110 mg/dL
Correct Answer: C
Expert Rationale
Hyponatremia, defined as a serum sodium level below 136 mEq/L, is a significant
electrolyte disturbance that can have profound neurological consequences. When
serum sodium falls to 123 mEq/L, it represents a severe and potentially life-
threatening imbalance that commonly manifests with confusion, lethargy,
disorientation, muscle weakness, and in extreme cases, seizures or coma. The
underlying pathophysiology involves osmotic fluid shifts; the low extracellular
sodium concentration creates an osmotic gradient that draws water into the
brain's cells, leading to cerebral edema. This intracellular swelling increases
intracranial pressure and disrupts normal neuronal function, producing the
observed cognitive and neurological deficits.
Option A is incorrect because a serum potassium level of 5.2 mEq/L falls within
the normal range of 3.5 to 5.0 mEq/L and is only mildly elevated. While
hyperkalemia can affect cardiac conduction and muscle function, it is not typically
associated with confusion as a primary manifestation.
Option B is incorrect because a serum calcium level of 10.8 mg/dL represents mild
hypercalcemia (normal range: 8.5 to 10.5 mg/dL). Although severe hypercalcemia
,can cause neurological symptoms such as confusion and altered mental status, the
elevation noted here is relatively modest and less likely to be the primary cause of
confusion when compared with the significantly low sodium level.
Option D is incorrect because a serum glucose level of 110 mg/dL is within normal
limits (70 to 110 mg/dL). While both hypoglycemia and severe hyperglycemia can
cause confusion, this value does not indicate a glucose disturbance that would
explain the client's symptoms.
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Question
A nurse is performing a comprehensive neurological assessment on a client. As
part of the examination, the nurse plans to evaluate the client's balance and
coordination. The nurse should stand in close proximity to the client for safety
purposes while the client performs which of the following diagnostic tests?
a. Heel-to-shin test
b. Romberg test
c. Finger-to-nose test
d. Gait assessment
Correct Answer: B
Expert Rationale
The Romberg test is a standardized assessment used to evaluate the client's sense
of balance and proprioception, specifically assessing the integrity of the dorsal
columns of the spinal cord. During this test, the client is instructed to stand with
feet together, arms at the sides, and eyes closed. This position removes visual cues
that help maintain balance, requiring the client to rely solely on proprioceptive
input and vestibular function. Because the client is at significant risk of falling
during this assessment due to the intentional removal of visual stabilization and
the challenge to their balance system, the nurse must remain in close proximity to
provide immediate physical support and prevent injury. A positive Romberg test,
,indicated by significant swaying or loss of balance, suggests dysfunction in the
proprioceptive pathways.
Option A is incorrect because the heel-to-shin test assesses lower extremity
coordination and motor function rather than balance and equilibrium. While the
nurse may observe the client during this test, the risk of falling is considerably
lower than with the Romberg test since the client is typically seated or supine.
Option C is incorrect because the finger-to-nose test evaluates upper extremity
coordination and cerebellar function. The client performs this test while seated or
lying down, significantly reducing the risk of falls and eliminating the need for the
nurse to stand in close proximity for safety purposes.
Option D is incorrect because while gait assessment evaluates balance and
coordination, the nurse typically observes the client's walking pattern from a short
distance rather than standing directly next to them. The question specifically asks
about standing nearby for safety, which is most critical for the static balance
challenge of the Romberg test.
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
Question
A nurse is preparing to obtain a wound culture specimen from a client who has an
infected surgical incision. Which of the following actions should the nurse take
when collecting the specimen to ensure accurate results?
a. Cleanse the wound with povidone-iodine solution before obtaining the
specimen
b. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the
specimen
c. Collect the specimen from the center of the wound using a dry cotton swab
d. Obtain the specimen from the wound drainage present on the old dressing
Correct Answer: B
, Expert Rationale
When obtaining a wound culture specimen, the fundamental principle is to collect
a sample that accurately reflects the microorganisms present in the wound tissue
rather than surface contaminants or colonizing bacteria. The recommended
procedure involves gently cleansing the wound with sterile 0.9% sodium chloride
irrigation to remove surface debris, exudate, and transient bacteria that may have
colonized the wound surface. This ensures that the specimen obtained will
represent the deeper tissue pathogens responsible for the infection, leading to
accurate identification and appropriate antibiotic therapy.
Option A is incorrect because povidone-iodine or other antiseptic solutions should
not be used to cleanse a wound before obtaining a culture. These antimicrobial
agents can kill bacteria in the wound, potentially yielding false-negative results
and delaying appropriate treatment.
Option C is incorrect because the specimen should be collected from the deepest
area of the wound, preferably from viable tissue or the advancing margin, rather
than from the wound's center where surface contaminants may be present.
Additionally, the swab should be moistened with sterile saline to facilitate
bacterial collection.
Option D is incorrect because specimens should never be collected from old
dressings. Drainage on dressings may contain dead bacteria or contaminants and
does not represent the current infecting organisms present in the wound tissue.
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
Question
A nurse is using a portable ultrasound bladder scanner to determine a client's
postvoid residual volume. Which of the following actions should the nurse take to
ensure accurate measurement and client safety?
a. Position the scanner head directly over the symphysis pubis
b. Apply firm pressure to the scanner head once it is in position
2026-2027 100 QUESTION AND CORRECT ANSWERS
WITH RATIONALES RATED A GRADE.
Question
A nurse is providing care for an adult client who has recently become disoriented
and confused. When reviewing the client's most recent laboratory results, which
of the following findings should the nurse identify as a potential contributing
factor to the client's altered mental status?
a. Serum potassium level of 5.2 mEq/L
b. Serum calcium level of 10.8 mg/dL
c. Serum sodium level of 123 mEq/L
d. Serum glucose level of 110 mg/dL
Correct Answer: C
Expert Rationale
Hyponatremia, defined as a serum sodium level below 136 mEq/L, is a significant
electrolyte disturbance that can have profound neurological consequences. When
serum sodium falls to 123 mEq/L, it represents a severe and potentially life-
threatening imbalance that commonly manifests with confusion, lethargy,
disorientation, muscle weakness, and in extreme cases, seizures or coma. The
underlying pathophysiology involves osmotic fluid shifts; the low extracellular
sodium concentration creates an osmotic gradient that draws water into the
brain's cells, leading to cerebral edema. This intracellular swelling increases
intracranial pressure and disrupts normal neuronal function, producing the
observed cognitive and neurological deficits.
Option A is incorrect because a serum potassium level of 5.2 mEq/L falls within
the normal range of 3.5 to 5.0 mEq/L and is only mildly elevated. While
hyperkalemia can affect cardiac conduction and muscle function, it is not typically
associated with confusion as a primary manifestation.
Option B is incorrect because a serum calcium level of 10.8 mg/dL represents mild
hypercalcemia (normal range: 8.5 to 10.5 mg/dL). Although severe hypercalcemia
,can cause neurological symptoms such as confusion and altered mental status, the
elevation noted here is relatively modest and less likely to be the primary cause of
confusion when compared with the significantly low sodium level.
Option D is incorrect because a serum glucose level of 110 mg/dL is within normal
limits (70 to 110 mg/dL). While both hypoglycemia and severe hyperglycemia can
cause confusion, this value does not indicate a glucose disturbance that would
explain the client's symptoms.
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Question
A nurse is performing a comprehensive neurological assessment on a client. As
part of the examination, the nurse plans to evaluate the client's balance and
coordination. The nurse should stand in close proximity to the client for safety
purposes while the client performs which of the following diagnostic tests?
a. Heel-to-shin test
b. Romberg test
c. Finger-to-nose test
d. Gait assessment
Correct Answer: B
Expert Rationale
The Romberg test is a standardized assessment used to evaluate the client's sense
of balance and proprioception, specifically assessing the integrity of the dorsal
columns of the spinal cord. During this test, the client is instructed to stand with
feet together, arms at the sides, and eyes closed. This position removes visual cues
that help maintain balance, requiring the client to rely solely on proprioceptive
input and vestibular function. Because the client is at significant risk of falling
during this assessment due to the intentional removal of visual stabilization and
the challenge to their balance system, the nurse must remain in close proximity to
provide immediate physical support and prevent injury. A positive Romberg test,
,indicated by significant swaying or loss of balance, suggests dysfunction in the
proprioceptive pathways.
Option A is incorrect because the heel-to-shin test assesses lower extremity
coordination and motor function rather than balance and equilibrium. While the
nurse may observe the client during this test, the risk of falling is considerably
lower than with the Romberg test since the client is typically seated or supine.
Option C is incorrect because the finger-to-nose test evaluates upper extremity
coordination and cerebellar function. The client performs this test while seated or
lying down, significantly reducing the risk of falls and eliminating the need for the
nurse to stand in close proximity for safety purposes.
Option D is incorrect because while gait assessment evaluates balance and
coordination, the nurse typically observes the client's walking pattern from a short
distance rather than standing directly next to them. The question specifically asks
about standing nearby for safety, which is most critical for the static balance
challenge of the Romberg test.
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
Question
A nurse is preparing to obtain a wound culture specimen from a client who has an
infected surgical incision. Which of the following actions should the nurse take
when collecting the specimen to ensure accurate results?
a. Cleanse the wound with povidone-iodine solution before obtaining the
specimen
b. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the
specimen
c. Collect the specimen from the center of the wound using a dry cotton swab
d. Obtain the specimen from the wound drainage present on the old dressing
Correct Answer: B
, Expert Rationale
When obtaining a wound culture specimen, the fundamental principle is to collect
a sample that accurately reflects the microorganisms present in the wound tissue
rather than surface contaminants or colonizing bacteria. The recommended
procedure involves gently cleansing the wound with sterile 0.9% sodium chloride
irrigation to remove surface debris, exudate, and transient bacteria that may have
colonized the wound surface. This ensures that the specimen obtained will
represent the deeper tissue pathogens responsible for the infection, leading to
accurate identification and appropriate antibiotic therapy.
Option A is incorrect because povidone-iodine or other antiseptic solutions should
not be used to cleanse a wound before obtaining a culture. These antimicrobial
agents can kill bacteria in the wound, potentially yielding false-negative results
and delaying appropriate treatment.
Option C is incorrect because the specimen should be collected from the deepest
area of the wound, preferably from viable tissue or the advancing margin, rather
than from the wound's center where surface contaminants may be present.
Additionally, the swab should be moistened with sterile saline to facilitate
bacterial collection.
Option D is incorrect because specimens should never be collected from old
dressings. Drainage on dressings may contain dead bacteria or contaminants and
does not represent the current infecting organisms present in the wound tissue.
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
Question
A nurse is using a portable ultrasound bladder scanner to determine a client's
postvoid residual volume. Which of the following actions should the nurse take to
ensure accurate measurement and client safety?
a. Position the scanner head directly over the symphysis pubis
b. Apply firm pressure to the scanner head once it is in position
