ATI NU 160 Final Exam Spring 2025
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Free ATI NU 160 Final Exam Spring 2025 Questions
A nurse is planning care for a client who has Alzheimer’s disease and resides in a memory care unit. When considering activities for the client, which of the following factors should contribute to the nurse’s selection
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The nurse should choose activities based on the available supplies on the unit.
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The nurse should choose activities based on the number of residents on the unit that week.
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The nurse should schedule activities for the month that rotate, so that residents can try new things.
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The nurse should choose activities that the client and/or their family have expressed that the client used to enjoy before moving.
Explanation
Correct Answer D: The nurse should choose activities that the client and/or their family have expressed that the client used to enjoy before moving.
Explanation
Clients with Alzheimer’s benefit from familiar routines and personalized care. Choosing activities that reflect the client's past interests and hobbies can help promote comfort, engagement, and a sense of identity. Family input is vital in identifying meaningful past activities that the client may respond positively to, despite cognitive decline.
Why Other Options are Wrong:
A. The nurse should choose activities based on the available supplies on the unit.”
This approach is based on convenience, not person-centered care. Activities should meet the client’s emotional and cognitive needs—not simply what’s available.
B. The nurse should choose activities based on the number of residents on the unit that week.”
While staffing and group dynamics matter, activity selection should primarily reflect individual client preferences and history, especially for clients with dementia.
C. The nurse should schedule activities for the month that rotate, so that residents can try new things.”
Routine and familiarity are often more beneficial for clients with Alzheimer’s than variety. Introducing new, unfamiliar activities can be confusing or distressing.
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification
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Laboratory testing of serum potassium upon admission
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0.9% normal saline IV at 50 mL/hr continuous
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Bumetanide 1 mg IV bolus every 12 hr
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Morphine sulfate 2 mg IV bolus every 2 hr PRN pain
Explanation
Correct Answer B: 0.9% normal saline IV at 50 mL/hr continuous
Explanation:
In clients with acute heart failure following an MI, fluid balance is critical. Administering 0.9% normal saline (an isotonic solution) at a continuous rate may worsen fluid overload, leading to pulmonary edema or further strain on an already weakened heart. Such a prescription could be dangerous unless clearly justified, so it requires clarification.
Why Other Options are Wrong:
A. Laboratory testing of serum potassium upon admission:
This is appropriate because potassium levels must be closely monitored in heart failure patients, especially those receiving diuretics like bumetanide, which can cause hypokalemia. It helps prevent arrhythmias and other complications.
C. Bumetanide 1 mg IV bolus every 12 hr:
Bumetanide is a loop diuretic used to reduce fluid volume in heart failure. This prescription helps relieve symptoms such as pulmonary congestion and edema. It is appropriate and expected.
D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain:
Morphine can be used cautiously in acute MI for pain relief and to reduce anxiety and preload. While not used as frequently today, this dosage and route are within common PRN usage if monitored carefully.
Which of the following are recommended treatment options for Crohn’s disease
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Surgical intervention for fistulas
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Biologic medications
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Immunosuppressants
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Anti-inflammatory medications
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High-fiber diet
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Antidepressants
Explanation
Correct Answers:
A. Surgical intervention for fistulas
B. Biologic medications
C. Immunosuppressants
D. Anti-inflammatory medications
Explanation:
Crohn’s disease is a chronic inflammatory bowel disease that can affect any part of the GI tract. Treatment focuses on reducing inflammation, managing symptoms, and preventing complications.
A. Surgical intervention for fistulas: Fistulas are a common complication of Crohn’s and may require surgical correction.
B. Biologic medications: TNF inhibitors (e.g., infliximab) are used to reduce inflammation and induce remission.
C. Immunosuppressants: Medications such as azathioprine help reduce immune system activity.
D. Anti-inflammatory medications: Agents like mesalamine are used to reduce inflammation in the intestines.
Why Other Options are Wrong:
E. High-fiber diet:
Not typically recommended during active flares, as it can irritate the bowel. A low-residue diet is often preferred during exacerbations.
F. Antidepressants:
Not a primary treatment for Crohn’s. While they may help with psychological symptoms, they are not part of the standard therapeutic regimen.
. 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.
A nurse is assessing a client who has peripheral venous disease. Which of the following findings should the nurse recognize as a manifestation of peripheral venous disease
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Shiny appearance to the lower extremities
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Diminished hair growth on the lower extremities
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Swollen and enlarged veins
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Loss of pigmentation over the shin area
Explanation
Correct Answer C: Swollen and enlarged veins
Explanation:
Peripheral venous disease (PVD), also known as chronic venous insufficiency, results from weakened or damaged vein walls and valves. This causes blood to pool in the lower extremities, leading to swelling, varicosities (enlarged veins), and a feeling of heaviness or discomfort in the legs. These are hallmark signs of venous insufficiency.
Why Other Options are Wrong:
A. Shiny appearance to the lower extremities
This is more commonly associated with peripheral arterial disease (PAD) due to ischemia and skin thinning, not venous disease.
B. Diminished hair growth on the lower extremities
This is another sign of arterial insufficiency, reflecting poor circulation. It is not characteristic of venous disease.
D. Loss of pigmentation over the shin area
In venous disease, the skin may actually show hyperpigmentation, particularly a brownish discoloration due to hemosiderin deposits, not loss of pigmentation.
A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the nurse include when gathering a client history
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Have you had any trauma to the eye?
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Do you regularly lift heavy objects?
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How much sodium is in your diet?
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Do you wear sunglasses when in direct sunlight?
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Do you take steroids
Explanation
Correct Answers:
A. Have you had any trauma to the eye?
B. Do you regularly lift heavy objects?
E. Do you take steroids?
Explanation:
A. Have you had any trauma to the eye?
Eye trauma is a known risk factor for retinal detachment. Blunt or penetrating injuries can disrupt the retina and lead to detachment.
B. Do you regularly lift heavy objects?
Heavy lifting and straining can increase intraocular pressure, which may contribute to retinal detachment, particularly in those already at risk.
E. Do you take steroids?
Prolonged steroid use has been associated with changes in the eye, such as cataracts or weakening of the retinal tissue, increasing the risk of detachment.
Why the Other Options Are Incorrect:
C. How much sodium is in your diet?
Sodium intake is more closely related to blood pressure and fluid retention but is not directly linked to retinal detachment.
D. Do you wear sunglasses when in direct sunlight?
While protecting eyes from UV rays is important, it is not a known factor in retinal detachment and is therefore not a priority in this assessment.
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 preparing a plan of care for a client who is postoperative for retinal detachment. Which of the following instructions should the nurse include in the plan of care
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Refrain from lifting objects that weigh over 15 lb.
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Resume use of contact lenses 48 hr after the procedure.
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Driving will be permitted 12 to 24 hr after the procedure.
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Lie with the face up for 2 weeks following the procedure.
Explanation
Correct Answer D: Lie with the face up for 2 weeks following the procedure.
Explanation:
After retinal detachment surgery, especially when a gas bubble is used to hold the retina in place, positioning is critical. The client may be instructed to maintain a face-up or face-down position (depending on where the detachment was) for an extended period, often up to 2 weeks, to facilitate healing and retinal reattachment.
Why Other Options are Wrong:
A. Refrain from lifting objects that weigh over 15 lb.
While patients are advised to avoid heavy lifting, this statement alone is not as specific or universally prescribed as the positioning requirement, which is vital to recovery.
B. Resume use of contact lenses 48 hr after the procedure.
This is incorrect. Clients should avoid wearing contact lenses after eye surgery until cleared by the ophthalmologist, as it could disrupt healing.
C. Driving will be permitted 12 to 24 hr after the procedure.
Driving is typically not permitted within 24 hours after retinal surgery due to vision changes, sedation, and positioning instructions. It can take days to weeks for vision to stabilize.
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis
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Blood in the sputum
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Low-grade fever
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Weight gain
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Flushed cheeks
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Night sweats
Explanation
Correct Answers:
A. Blood in the sputum
B. Low-grade fever
E. Night sweats
Explanation:
A. Blood in the sputum
Hemoptysis, or coughing up blood, is a common symptom of pulmonary tuberculosis and indicates damage to lung tissue.
B. Low-grade fever
A persistent low-grade fever, particularly in the afternoon, is a typical symptom of TB due to the chronic inflammatory response.
E. Night sweats
Night sweats are a hallmark symptom of TB and result from the body’s immune response to the infection.
Why the Other Options Are Incorrect:
C. Weight gain
Clients with TB typically experience weight loss, not weight gain, due to decreased appetite and the body's metabolic demands from the infection.
D. Flushed cheeks
Flushed cheeks are not a typical sign of tuberculosis and are more commonly associated with fever from other causes or emotional responses.
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