ATI NCLEX CERTIFICATION EVALUATION
EXAMS 2026 FULL ANSWER KEY NCSBN BANK
◉ How should the nurse respond when a client asks the purpose of an
advance directive? Answer: The purpose of advance directives is to
communicate a client's wishes regarding end-of-life care should the
client become unable to do so. The PSDA requires asking all clients on
admission to a health care facility whether they have advance directives.
Staff should give clients who do not have advance directives written
information that outlines their rights related to health care decisions and
how to formulate advance directives. A health care representative should
be available to help with this process.
◉ List at least three (3) priority considerations when performing a sterile
dressing change. Answer: Prolonged exposure to airborne micro-
organisms can make sterile items non-sterile.
Avoid coughing, sneezing, and talking directly over a sterile field.
Air movement should be controlled by special ventilation.
Only sterile items may be in a sterile field.
◉ A nurse is caring for an elderly client with constipation. What are
three (3) complications to monitor for during care of this client? Answer:
Complications of constipation include: Fecal impaction. Development of
hemorrhoids or rectal fissures. Bradycardia, hypotension, and syncope
associated with the Valsalva maneuver (occurs with straining/bearing
down).
,◉ A nurse is caring for a client with severe nausea and vomiting. What
are manifestations of possible dehydration and the need for IV fluid
replacement? Answer: Manifestations of dehydration include:
hyperthermia (dehydration), tachycardia, thready pulse, hypotension,
orthostatic hypotension, decreased central venous pressure, tachypnea
(increased respirations), hypoxia, dizziness, syncope, confusion,
weakness, fatigue; seizures (rapid/severe dehydration), thirst, dry
mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia,
acute weight loss, oliguria, diminished capillary refill, cool clammy skin,
diaphoresis, sunken eyeballs, flattened neck veins, absence of tears,
decreased skin turgor
◉ A nurse is reviewing medications while preparing to administer
morning medications. List three (3) risk factors that can cause a decrease
in medication effectiveness. Answer: Risk factors that can cause a
decrease in medication effectiveness include increase body weight,
genetics, tolerance to the medication, inadequate gastric acid, diarrhea,
vascular insufficiency, and prolonged gastric emptying time.
◉ Discuss passive and active immunity. Answer: Passive: Antibodies are
produced by an external source. Temporary immunity that does not have
memory of past exposures. Intact skin, the body's first line of defense.
Mucous membranes, secretions, enzymes, phagocytic cells, and
protective proteins. Inflammatory response with phagocytic cells, the
complement system, and interferons to localize the invasion and prevent
its spread
, Active: Antibodies are produced in response to an antigen. Requires time
to react to antigens. Provides permanent immunity. Involves B- and T-
lymphocytes. Produces specific antibodies against specific antigens
(immunoglobulins [IgA, IgD, IgE, IgG, IgM])
◉ A client is prescribed a protease inhibitor—ritonavir. Identify three (3)
nursing considerations when administering a protease inhibitor. Answer:
Instruct client to report all other the counter medications; except for
indinavir, take protease inhibitors with food to increase absorption;
administer with another antiretroviral; advise barrier form of
contraception; advise diet high in calcium and vitamin D.
◉ A client has been prescribed oxybutynin for treatment of overactive
bladder and has been experiencing anticholinergic side effects. List two
(2) actions the client will take to prevent adverse effects of the
medication therapy. Answer: Adverse Effects of oxybutynin:
Constipation, dry mouth, blurred vision, photophobia, dry eyes, CNS
effects (hallucinations, confusion, insomnia and nervousness)
Client Actions:
Increase dietary fiber; Consume 2 to 3 L/day of fluid from beverage;
Avoid hazardous activities if my vision is impaired
◉ A nurse has provided education to a client who has a new prescription
for brimonidine ophthalmic drops. What statements by the client would
indicate they understand the instructions? Answer: The following client
statements indicate understanding of the nurse education concerning
their brimonidine ophthalmic drops: May experience Localized stinging
EXAMS 2026 FULL ANSWER KEY NCSBN BANK
◉ How should the nurse respond when a client asks the purpose of an
advance directive? Answer: The purpose of advance directives is to
communicate a client's wishes regarding end-of-life care should the
client become unable to do so. The PSDA requires asking all clients on
admission to a health care facility whether they have advance directives.
Staff should give clients who do not have advance directives written
information that outlines their rights related to health care decisions and
how to formulate advance directives. A health care representative should
be available to help with this process.
◉ List at least three (3) priority considerations when performing a sterile
dressing change. Answer: Prolonged exposure to airborne micro-
organisms can make sterile items non-sterile.
Avoid coughing, sneezing, and talking directly over a sterile field.
Air movement should be controlled by special ventilation.
Only sterile items may be in a sterile field.
◉ A nurse is caring for an elderly client with constipation. What are
three (3) complications to monitor for during care of this client? Answer:
Complications of constipation include: Fecal impaction. Development of
hemorrhoids or rectal fissures. Bradycardia, hypotension, and syncope
associated with the Valsalva maneuver (occurs with straining/bearing
down).
,◉ A nurse is caring for a client with severe nausea and vomiting. What
are manifestations of possible dehydration and the need for IV fluid
replacement? Answer: Manifestations of dehydration include:
hyperthermia (dehydration), tachycardia, thready pulse, hypotension,
orthostatic hypotension, decreased central venous pressure, tachypnea
(increased respirations), hypoxia, dizziness, syncope, confusion,
weakness, fatigue; seizures (rapid/severe dehydration), thirst, dry
mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia,
acute weight loss, oliguria, diminished capillary refill, cool clammy skin,
diaphoresis, sunken eyeballs, flattened neck veins, absence of tears,
decreased skin turgor
◉ A nurse is reviewing medications while preparing to administer
morning medications. List three (3) risk factors that can cause a decrease
in medication effectiveness. Answer: Risk factors that can cause a
decrease in medication effectiveness include increase body weight,
genetics, tolerance to the medication, inadequate gastric acid, diarrhea,
vascular insufficiency, and prolonged gastric emptying time.
◉ Discuss passive and active immunity. Answer: Passive: Antibodies are
produced by an external source. Temporary immunity that does not have
memory of past exposures. Intact skin, the body's first line of defense.
Mucous membranes, secretions, enzymes, phagocytic cells, and
protective proteins. Inflammatory response with phagocytic cells, the
complement system, and interferons to localize the invasion and prevent
its spread
, Active: Antibodies are produced in response to an antigen. Requires time
to react to antigens. Provides permanent immunity. Involves B- and T-
lymphocytes. Produces specific antibodies against specific antigens
(immunoglobulins [IgA, IgD, IgE, IgG, IgM])
◉ A client is prescribed a protease inhibitor—ritonavir. Identify three (3)
nursing considerations when administering a protease inhibitor. Answer:
Instruct client to report all other the counter medications; except for
indinavir, take protease inhibitors with food to increase absorption;
administer with another antiretroviral; advise barrier form of
contraception; advise diet high in calcium and vitamin D.
◉ A client has been prescribed oxybutynin for treatment of overactive
bladder and has been experiencing anticholinergic side effects. List two
(2) actions the client will take to prevent adverse effects of the
medication therapy. Answer: Adverse Effects of oxybutynin:
Constipation, dry mouth, blurred vision, photophobia, dry eyes, CNS
effects (hallucinations, confusion, insomnia and nervousness)
Client Actions:
Increase dietary fiber; Consume 2 to 3 L/day of fluid from beverage;
Avoid hazardous activities if my vision is impaired
◉ A nurse has provided education to a client who has a new prescription
for brimonidine ophthalmic drops. What statements by the client would
indicate they understand the instructions? Answer: The following client
statements indicate understanding of the nurse education concerning
their brimonidine ophthalmic drops: May experience Localized stinging
