2025 NURS 226 ATI Practice OFFICIAL STUDY RESOURCE: FULL TEST BANK WITH RATIONALES 2026 COMPLETE EXAM SOLUTION - MULTIPLE VERSIONS INCLUDED complete Review Guide with Practice Questions, RationaleCs, and Expert Strategies for Guaranteed Success W

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? • A. To confirm the placement of the NG tube • B. To remove gastric acid that might cause dyspepsia • C. To determine the client's electrolyte balance • D. To identify delayed gastric emptying Rationale: Measuring gastric residual volume (GRV) identifies how much of the previous feeding remains in the stomach. An excessively high residual indicates delayed gastric emptying, which increases the client's risk for gastric distension, nausea, vomiting, and potentially fatal pulmonary aspiration. (Tube placement should be verified via pH testing or X-ray, not GRV). 2. Clinical Prioritization and Workflow at Shift Change A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postop following a partial bowel resection, requires a dressing change, total parenteral nutrition (TPN) administration, and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? • A. Weigh the second client • B. Obtain vital signs for both clients • C. Administer pain meds to the first client • D. Change the dressings of both clients Rationale: Assessment is always the first step of the nursing process. Obtaining baseline vital signs for both clients at the start of the shift establishes physical stability and rules out immediate life-threatening complications (such as hemorrhage or sepsis in a fresh post-op client) before the nurse dives into localized procedures or scheduled interventions. 3. Needle Safety and Infection Control A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? • A. Recap the needle • B. Place the cap on the bedside table and slide the needle into the cap • C. Wrap the needle with gauze • D. Dispose of the needle uncapped Rationale: To prevent accidental needlestick injuries and exposure to bloodborne pathogens (like Hepatitis C or HIV), OSHA and standard precautions mandate that needles must never be recapped, bent, broken, or manually manipulated after client use. The entire assembly must be dropped immediately into a biohazard sharps container uncapped. 4. Diagnostic Markers for Chronic Malnutrition A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? • A. Creatine kinase • B. Troponin • C. Total bilirubin • D. Albumin Rationale: Albumin is a plasma protein synthesized by the liver. Because it has a half-life of roughly 20 days, decreased serum albumin levels serve as a classic diagnostic marker for chronic protein-calorie malnutrition or prolonged metabolic wasting. (Creatine kinase and troponin are cardiac/muscle injury markers). 5. Manifestations of Urinary Retention A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention? • A. Client who has an elevated BUN B. A client who reports painful urination C. A client who reports urinary frequency • D. A client who has glucose in his urine Rationale: When a client experiences urinary retention, the bladder is unable to empty completely. As the bladder overfills, the intravesical pressure overcomes urethral resistance, causing small amounts of urine to leak out continuously or frequently (overflow incontinence), which manifests clinically as urinary frequency. 6. Etiology of Constipation [Select all that apply] A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? • A. Excessive laxative use • B. Ignoring the urge to defecate • C. Inadequate fluid intake • D. Increased fiber in the diet • E. Increased activity Rationale: Chronic, excessive laxative use (A) desensitizes the bowel's natural neuromuscular reflexes, making the colon dependent on artificial stimulation. Ignoring the urge to defecate (B) allows the colon to reabsorb excess water from the stool, hardening it. Inadequate fluid intake (C) dries out the stool matrix. Conversely, increased dietary fiber and increased physical activity promote healthy peristalsis and alleviate constipation. 7. Early Physiological Compensations for Hypoxia A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? • A. Bradypnea • B. Somnolence • C. Pallor • D. Tachycardia Rationale: When systemic tissues experience oxygen deprivation (hypoxia), the body's sympathetic nervous system triggers an immediate compensatory release of epinephrine and norepinephrine. This response increases the heart rate (tachycardia) and cardiac output to maximize the delivery of available oxygen to vital organs. 8. Routes of Medication Administration: Sublingual vs. Enteral A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? • A. Request a prescription for an oral formulation of the medication • B. Administer the crushed medication through the NG tube • C. Dissolve the medication in water and give it through the NG tube • D. Administer the medication under the client's tongue Rationale: Sublingual medications are designed to dissolve under the tongue and absorb directly into the systemic circulation via the highly vascular oral mucosa, completely bypassing the gastrointestinal tract and liver metabolism. Having an NG tube in place does not interfere with oral sublingual pathways, so the medication should be given exactly as prescribed. 9. Maintaining Medication Safety During Emergencies A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take? • A. Have another nurse guard the medication preparations until the nurse returns • B. Have another nurse finish preparing the meds • C. Lock the meds in a room and finish preparing it after returning from the emergency • D. Discard the prepared meds and begin again after returning Rationale: The nurse who prepares a medication is legally and professionally responsible for its accurate setup, checking, and administration. In an emergency, the nurse must secure the prepared doses in a locked medication room or cart to prevent theft, tampering, or administration errors by unauthorized personnel, resuming the task safely upon return. 10. Localized Indicators of Catheter-Associated Urinary Tract Infections A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? • A. Pernicious anemia • B. Dehydration C. Bladder infection D. Prostate enlargement Rationale: Hematuria (blood-tinged urine) in a client with an indwelling urinary catheter is a classic manifestation of a localized urinary tract or bladder infection. The microbial invasion inflames the mucosal lining of the bladder, causing capillary micro-bleeding into the urine stream. 11. Expected Outcomes Following Catheter Removal A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? • A. Temporary urinary retention • B. Urinary frequency for several days • C. Blood-tinged urine • D. Highly concentrated urine Rationale: Prolonged or even short-term bladder catheterization can temporarily desensitize the detrusor muscle stretching reflexes and cause mild periurethral edema. As a result, temporary urinary retention or difficulty initiating a void is a common, highly monitored expected outcome during the first 6 to 8 hours following catheter removal. 12. Correct Aseptic Action for Dropped Medications A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? • A. Use the tablet's packaging to pick it up from the counter • B. Wash the tablet off with alcohol and place it in a clean medication cup • C. Discard the tablet and obtain another dose of medication • D. Place the tablet directly into a medication cup Rationale: Once a medication contacts an unsterile, contaminated surface such as a countertop, it is considered dirty and cannot be administered to a client. Washing oral tablets with alcohol destroys the drug matrix. The only safe, aseptic choice is to discard the dropped tablet according to facility policy and draw up a fresh dose. 13. Technique for Nasal Drop Instillation A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? • A. Tell the client to blow her nose gently before the instillation • B. Assist the client to a side-lying position • C. Hold the dropper 2 cm (1 in) above the naris • D. Instruct the client to stay in the same position for 2 min Rationale: Having the client clear their nasal passages by blowing their nose gently beforehand ensures that the mucous membranes are cleared of debris. This maximizes direct contact and absorption of the medication. (The dropper should be held about $1text{ cm}$ above the nares, and the client should remain in position for 5 minutes). 14. Prioritizing Least Restrictive Interventions for Acute Confusion A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? • A. Call the family and ask them to stay with the client • B. Move the client to a room closer to the nurse's station • C. Apply wrist and leg restraints to the client • D. Administer medication to sedate the client Rationale: When managing an acutely confused client, nursing interventions must follow the least restrictive framework. Moving the client close to the nurse's station permits constant visual surveillance and rapid intervention without resorting to chemical sedation or physical restraints, both of which increase the risk of delirium and falls in older adults. 15. Alternatives to Physical Restraints [Select all that apply] A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? • A. Explain to the client that he will be restrained if he does not stop pulling on his NG tube • B. Assist the client with toileting at frequent intervals • C. Use an electronic position-sensitive device D. Provide diversionary activities for the client E. Involve the family in the client's care Rationale: Restraints are an intervention of absolute last resort. Legitimate, non-restrictive alternatives include addressing underlying physical discomforts via scheduled toileting (B), tracking movements non-invasively with position sensors (C), using focal redirections like folding washcloths or therapeutic activities (D), and utilizing family presence for bedside reorientation and calming support (E). Threatening a cognitively impaired client (A) is unethical, ineffective, and inappropriate. 16. Prioritizing Fire Safety Protocols (R.A.C.E.) A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? • A. Close the fire doors on the unit • B. Activate the fire alarm • C. Move any clients in the immediate vicinity • D. Use a fire extinguisher to put out the fire Rationale: Following the standard, foundational R.A.C.E. protocol for healthcare fire safety: 1. R = Rescue / Remove clients in immediate danger (Highest Priority) 2. A = Alarm (Activate fire pull stations) 3. C = Confine / Contain (Close fire doors) 4. E = Extinguish (Evacuate or fight fire using PASS technique)