ATI NU 160 Final Exam Spring 2025
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Free ATI NU 160 Final Exam Spring 2025 Questions
A nurse is completing an admission assessment on a client who has hearing loss. Which of the following client statements should indicate to the nurse that the client is experiencing manifestations of Ménière’s disease
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I can’t get out of bed because the room is spinning.
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I did feel some fluid dripping from my ear when I laid down.
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Sometimes I feel slightly dizzy when I am in a loud restaurant.
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I often feel like I have cotton balls in my ears.
Explanation
Correct Answer A: I can’t get out of bed because the room is spinning.
Explanation:
Ménière’s disease is an inner ear disorder characterized by episodes of severe vertigo (a sensation of spinning), hearing loss, tinnitus, and a feeling of fullness in the ear. Vertigo is often so intense that clients cannot stand or walk safely, and they may experience nausea and vomiting during episodes.
Why Other Options are Wrong:
B. I did feel some fluid dripping from my ear when I laid down.
This suggests possible otitis media or ruptured tympanic membrane but is not typical of Ménière’s disease, which involves inner ear dysfunction—not external drainage.
C. Sometimes I feel slightly dizzy when I am in a loud restaurant.
Mild dizziness in noisy environments may relate to sensory overload or other vestibular issues, but the hallmark of Ménière’s disease is episodic, severe vertigo, not slight dizziness.
D. I often feel like I have cotton balls in my ears.
This implies a sensation of fullness or mild hearing impairment but lacks the severity and associated vertigo seen in Ménière’s disease. While fullness is a feature, it alone is not diagnostic.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication
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Antiplatelet aggregate
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Antipyretic
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Anti-inflammatory
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Analgesic
Explanation
Correct Answer A: Antiplatelet aggregate
Explanation:
Aspirin is given in the context of myocardial infarction (MI) for its antiplatelet effect. It inhibits the formation of thromboxane A2, which reduces platelet aggregation. This action helps prevent the formation of blood clots, which is critical in reducing the risk of recurrent MI and promoting blood flow in coronary arteries.
Why Other Options are Wrong:
B. Antipyretic
While aspirin does reduce fever, this property is not the reason it is used in the treatment or prevention of MI.
C. Anti-inflammatory
Aspirin has anti-inflammatory properties at higher doses, but in the case of MI, the dose prescribed (often 81–325 mg) is specifically for its cardioprotective antiplatelet action, not inflammation.
D. Analgesic
Although aspirin can reduce pain, this is not its primary purpose in the treatment of MI. Other medications are typically used for pain control in that setting.
A nurse is caring for a client in the emergency department.
History and Physical
21-year-old client diagnosed with type 1 diabetes mellitus at age 12 years old.
2 days ago:
Started experiencing nausea, vomiting, and abdominal pain.
Reports frequent urge to urinate.
Today:
Reports increased thirst and blurry vision. Continues to be nauseated without any emesis. No complaints of pain.
Laboratory Results
Sodium 135 mEq/L (135 to 145 mEq/L)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Glucose 300 mg/dL (74 to 106 mg/dL)
Calcium 9.8 mg/dL (9.0 to 10.5 mg/dL)
Chloride 100 g/dL (98 to 106 g/dL)
BUN 22 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (female: 0.5 to 1.1 mg/dL: male: 0,6 to 1.2 mg/dL)
C-peptide 5.6 ng/mt (fasting 0.78 to 1.89 ng/mL)
Urinalysis:
Ketones: positive (none)
Leukocytes: esterase positive (none)
Red blood cells: 5 per high power field (less than 2 per high power field)
Indicative of UTI
ABG:
pH 7.20 (7.35 to.7.45)
PaCO2 35 mm Hg (35 to 45 mm Hg)
PaO2 85 (70 to 100 mm Hg)
HCO3. 12 mEq/L (22 to 26 mEq/L)
Vital Signs
Temp 36.7° C (98.1* F)
Blood pressure 128/86 mm Hg
Heart rate 98/min
Respiratory rate 26/min
SaO2 96%
A nurse is caring for a client in the emergency department. Which of the following assessment findings would indicate to the nurse that the client is at risk for developing diabetic ketoacidosis (DKA)
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Ketones present in urine
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Elevated C-peptide blood level
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Serum blood glucose 300 mg/dL
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HbA1c 12.6%
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Hypertension
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ABG results
Explanation
Correct Answers:
A. Ketones present in urine
C. Serum blood glucose 300 mg/dL
D. HbA1c 12.6%
F. ABG results
Explanation:
A. Ketones present in urine
Positive ketones in urine are a hallmark of DKA, indicating fat breakdown due to insulin deficiency.
C. Serum blood glucose 300 mg/dL
Marked hyperglycemia is a defining feature of DKA. A glucose level above 250 mg/dL is commonly seen in DKA cases.
D. HbA1c 12.6%
This elevated HbA1c indicates poor long-term blood glucose control, increasing the risk for DKA.
F. ABG results
The ABG reveals metabolic acidosis: low pH (7.20) and low bicarbonate (HCO₃ 12 mEq/L), which are consistent with DKA.
Why the Other Options Are Incorrect:
B. Elevated C-peptide blood level
C-peptide is typically low or absent in type 1 diabetes, especially in DKA. An elevated level may indicate type 2 diabetes or exogenous insulin is not the primary source.
E. Hypertension
Hypertension is not a typical indicator of DKA. DKA often presents with normal or even low blood pressure due to dehydration.
A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching
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I will make a list of my favorite beverages.
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I will not add ice cream to the amount of fluid intake.
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I will put beverages in large containers to give the appearance of drinking a lot.
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I should consume most of the fluid during the evening.
Explanation
Correct Answer A: I will make a list of my favorite beverages.
Explanation:
Clients with acute kidney injury must strictly monitor fluid intake to avoid volume overload. Making a list of favorite beverages helps patients prioritize which fluids they enjoy most and plan their daily intake wisely. It reflects understanding and participation in self-management.
Why Other Options are Wrong:
B. I will not add ice cream to the amount of fluid intake.
This reflects a misunderstanding. Foods like ice cream, gelatin, and soup must be counted toward total fluid intake because they melt into liquid. Excluding them could lead to unintentional fluid overload.
C. I will put beverages in large containers to give the appearance of drinking a lot.
This strategy can be misleading. The goal is to limit actual intake, not create an illusion. This statement shows the client is trying to trick themselves, which is not appropriate for managing a strict restriction.
D. I should consume most of the fluid during the evening.
This can lead to discomfort, nocturia, and sleep disturbances. Fluids should be spaced evenly throughout the day to avoid complications and ensure better management of fluid balance.
A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching
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I will keep my legs in a dependent position.
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I will decrease my activity to prevent added stress on my legs.
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I will need to massage my legs frequently to prevent a buildup of fluid.
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I will inspect my legs every day for changes in color, size, and temperature.
Explanation
Correct Answer D: I will inspect my legs every day for changes in color, size, and temperature.
Explanation:
Daily inspection of the legs for color, temperature, and size helps in early identification of complications such as venous ulcers, infections, or worsening circulation. Clients with peripheral venous disease (PVD) are at risk for chronic venous insufficiency, so skin monitoring is a key self-care strategy.
Why Other Options are Wrong:
A. I will keep my legs in a dependent position.
Keeping legs in a dependent (lowered) position worsens venous pooling and can exacerbate edema and discomfort. Elevation, not dependency, is recommended to promote venous return.
B. I will decrease my activity to prevent added stress on my legs.
Physical activity, especially walking, actually improves venous return and circulation. Clients should be encouraged to maintain regular activity unless contraindicated.
C. I will need to massage my legs frequently to prevent a buildup of fluid.
Massaging legs in clients with venous disease is not recommended, especially if there’s any risk of clots or thrombosis, as it may dislodge thrombi and cause embolic events.
A client with peptic ulcer disease is prescribed sucralfate. What is the primary action of sucralfate in the treatment of ulcers
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Sucralfate promotes healing of the ulcer by increasing blood flow to the area
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Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.
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Sucralfate neutralizes stomach acid.
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Sucralfate inhibits the growth of H. pylori bacteria.
Explanation
Correct Answer B: Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.
Explanation:
B. Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.
Sucralfate is a medication that works by forming a protective barrier over the ulcer. This barrier helps protect the ulcer from the damaging effects of stomach acid and pepsin, promoting healing. It does not directly affect the acid production or the bacteria but instead protects the ulcerated area.
Why the Other Options Are Incorrect:
A. Sucralfate promotes healing of the ulcer by increasing blood flow to the area.
Sucralfate does not increase blood flow to the ulcer. Its primary function is to form a protective barrier over the ulcer, which helps in healing, but it doesn't enhance blood circulation.
C. Sucralfate neutralizes stomach acid.
This is incorrect because sucralfate does not neutralize stomach acid. Medications such as antacids or proton pump inhibitors (PPIs) are used for neutralizing stomach acid. Sucralfate works differently by creating a protective coating on the ulcer.
D. Sucralfate inhibits the growth of H. pylori bacteria.
Sucralfate does not directly inhibit H. pylori growth. While H. pylori infection is a common cause of peptic ulcers, sucralfate does not target the bacteria itself. H. pylori infections are typically treated with antibiotics or proton pump inhibitors.
A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect
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Severe myopia
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Photopsia
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Vertigo
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Anosmia
Explanation
Correct Answer C. Vertigo
Explanation:
Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, hearing loss, and a sensation of fullness in the ear. Vertigo—often sudden and intense—is one of the hallmark symptoms and can last from minutes to hours, greatly impacting balance and quality of life.
Why Other Options are Wrong:
A. Severe myopia
This refers to nearsightedness and is not related to the inner ear or balance systems affected in Meniere’s disease.
B. Photopsia
This describes flashes of light in the vision, typically related to retinal issues, such as retinal detachment—not Meniere’s disease.
D. Anosmia
Anosmia means the loss of the sense of smell and is associated with olfactory issues, not auditory or vestibular dysfunction as seen in Meniere’s disease.
A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of the following statements should the nurse include in the teaching
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You should practice deep breathing exercises.
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You should avoid exercising.
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You can use at least 2,300 mg of sodium daily.
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You can have 2 to 3 cups of coffee throughout the day.
Explanation
Correct Answer A: You should practice deep breathing exercises.
Explanation:
Tinnitus, or ringing in the ears, can be worsened by stress, anxiety, and certain lifestyle habits. Deep breathing exercises promote relaxation, reduce stress levels, and may help lessen the perception and severity of tinnitus episodes. Stress reduction is one of the primary non-medication strategies for managing tinnitus.
Why Other Options are Wrong:
B. You should avoid exercising.
Avoiding exercise is not helpful and can actually worsen stress and overall health, which can contribute to tinnitus symptoms. Exercise is generally encouraged to improve circulation, reduce anxiety, and enhance well-being.
C. You can use at least 2,300 mg of sodium daily.
High sodium intake can worsen fluid retention and affect inner ear pressure, which may aggravate tinnitus. Clients are often advised to reduce sodium as part of managing tinnitus and other inner ear disorders.
D. You can have 2 to 3 cups of coffee throughout the day.
Caffeine can sometimes worsen tinnitus by stimulating the nervous system and increasing anxiety or excitability. Clients with tinnitus are usually advised to limit or avoid caffeine to see if it improves symptoms.
. A nurse is caring for a client who has type 2 diabetes mellitus and their glucose levels are rising. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)
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Hypertension
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Plasma osmolarity of 350 mOsm/L
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Ketosis
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Glucose level of 500 mg/dL
Explanation
Correct Answer B: Plasma osmolarity of 350 mOsm/L
Explanation:
B. Plasma osmolarity of 350 mOsm/L
HHS is characterized by extremely high blood glucose levels and increased plasma osmolarity, usually above 320 mOsm/L. A level of 350 mOsm/L confirms the presence of this hyperosmolar state, which leads to severe dehydration and altered mental status.
Why the Other Options Are Incorrect:
A. Hypertension
Hypertension can be present with many conditions and is not specific to HHS. It is not a defining feature.
C. Ketosis
Ketosis is typical of diabetic ketoacidosis (DKA), not HHS. In HHS, ketosis is minimal or absent due to the presence of some insulin activity.
D. Glucose level of 500 mg/dL
While elevated glucose supports the possibility of HHS, glucose levels in HHS often exceed 600 mg/dL. A level of 500 mg/dL alone is not definitive
A nurse working in a pediatric inpatient unit is teaching the parents of a 10-year-old child who has suspected appendicitis about non-pharmacological pain control measures. Which statement by the parents indicates an understanding of the teaching
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Applying a warm compress to our child’s abdomen can help ease the pain.
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Gently massaging our child’s abdomen in a circular motion can help.
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Having our child pull their legs closer to their chest might provide relief.
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We should encourage our child to lie flat on their back to rest.
Explanation
Correct Answer C: Having our child pull their legs closer to their chest might provide relief.
Explanation:
For children with suspected appendicitis, the fetal position or pulling legs toward the chest can reduce abdominal muscle tension and help relieve pain. This is a safe, non-pharmacologic approach to ease discomfort until surgical intervention or further evaluation.
Why Other Options are Wrong:
A. Applying a warm compress to our child’s abdomen can help ease the pain.
Heat should be avoided in suspected appendicitis because it can increase blood flow and potentially lead to rupture if the appendix is inflamed.
B. Gently massaging our child’s abdomen in a circular motion can help."
Massage is contraindicated as it can stimulate the area and worsen pain or cause complications if inflammation is present
D. We should encourage our child to lie flat on their back to rest."
This position may increase discomfort in appendicitis. Children instinctively avoid lying flat and prefer positions that reduce abdominal strain.
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