ATI NCLEX 2022 Test Bank Questions
1. A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the
client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations
24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated
with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit?
(Select all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea Correct Answer: 1. A. CORRECT: Decreased skin turgor is a clinical manifestation present
with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results
in dryness of the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is
concentrated due to urinary output being decreased.
C. INCORRECT: Bradycardia is not a clinical manifestation present with fluid volume deficit.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade
fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
2. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2
lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal
cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness Correct Answer: 2. A. CORRECT: Dyspnea is a clinical manifestation present with fluid
volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is
struggling to breathe to obtain oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the
excess of fluid within the body. Weight gain can be a result of edema.
C. INCORRECT: Bradycardia is not a clinical manifestation related to fluid volume excess.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due to
the excess fluid that is retained, which depletes energy and increases the workload for the body.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
,3. A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should
the nurse assess for that is indicative of fluid volume deficit?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia Correct Answer: 3. A. INCORRECT: Moist skin is a clinical manifestation indicative of fluid
volume excess.
B. INCORRECT: Distended neck veins is a clinical manifestation indicative of fluid volume excess.
C. INCORRECT: Increased urinary output is a clinical manifestation indicative of fluid volume excess.
D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of
fluid volume deficit.
4. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and
confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C
(100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb
and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with
diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake.
B. Observe for signs of hypertension.
C. Encourage the client to ambulate to promote oxygenation.
D. Monitor respirations for shortness of breath. Correct Answer: 4. A. INCORRECT: The nurse should not
initiate fluid restrictions to limit intake. This would be an appropriate action for a client who has fluid
volume excess. The client is dehydrated, and fluids should be encouraged.
B. INCORRECT: The nurse should not be monitoring for signs of hypertension. This would be an
appropriate action for a client who has fluid volume excess. The client is hypotensive due to fluid volume
depletion. The nurse should monitor the client for hypotension.
C. INCORRECT: The nurse should not encourage the client to ambulate to promote oxygenation. This
would be an appropriate action for a client who has fluid volume excess. The client is experiencing
dizziness due to dehydration and is at risk for falling. The nurse should keep the client in bed and assist
him to the bathroom as needed.
D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for
shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right
lower lobe. This client is dehydrated and has fluid volume deficit.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
5. A nurse is planning caring for a client who is experiencing fluid volume excess. Which nursing actions
should the nurse include in the plan of care? Describe three interventions the nurse should take. Correct
Answer: 5. Check ABGs, SaO2, CBC, and chest x-ray results. ◯ Position the client in a semi-Fowler's
position. ◯ Obtain daily weight. ◯ Monitor intake and output. ◯ Administer supplemental oxygen as
prescribed. ◯ Reduce IV flow rates. ◯ Administer diuretics (osmotic, loop) as prescribed. ◯ Limit
fluid and sodium intake as prescribed. ◯ Monitor and document presence of edema (pretibial, sacral,
periorbital). ◯ Reposition the client at least every 2 hr. ◯ Support arms and legs to decrease
dependent edema as appropriate. ◯ Monitor vital signs and heart rhythm. ◯ Auscultate lung sounds
(listen for crackles).
,1. A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L.
Which of the following treatments can result in these laboratory findings?
A. Three tap water enemas
B. 0.9% sodium chloride solution IV at 50 mL/hr
C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
D. Administration of glucocorticoids Correct Answer: 1. A. CORRECT: Receiving three tap water enemas
can result in a decrease in serum sodium and potassium in the client. Tap water is hypotonic, and
gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.
B. INCORRECT: Receiving 0.9% sodium chloride solution IV at 50 mL/hr would not produce these results.
C. INCORRECT: Receiving 5% dextrose in water solution with 20 mEq of K+ at 80 mL/hr would not
produce these results.
D. INCORRECT: Receiving glucocorticoids would not produce these results.
3. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The
nurse should monitor for which of the following electrolyte imbalances?
A. Hypercalcemia
B. Hyponatremia
C. Hyperphosphatemia
D. Hypomagnesemia Correct Answer: 3. A. INCORRECT: An increase in calcium is not indicated with
nasogastric losses due to suctioning.
B. CORRECT: The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and
contain sodium.
C. INCORRECT: An increase in phosphatemia is not indicated with nasogastric losses due to suctioning.
D. INCORRECT: A decrease in magnesium is not indicated with nasogastric losses due to suctioning
4. A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse
use to perform this test?
A. Apply a blood pressure cuff to the client's arm.
B. Place the stethoscope bell over the client's carotid artery.
C. Tap lightly on the client's cheek.
D. Ask the client to lower his chin to his chest. Correct Answer: 4. A. INCORRECT: This is performed to
assess for Trousseau's sign.
B. INCORRECT: This is performed to auscultate a carotid bruit.
C. CORRECT: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to
elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this
side of his face.
D. INCORRECT: This is performed to assess for range of motion of the neck.
1. A nurse is caring for a client admitted with confusion and lethargy. The client was found at home
unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of
104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and
deep. Which of the following arterial blood gases findings should the nurse expect?
A. pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 24 mEq/L
, B. pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L Correct Answer: 1. A. INCORRECT:
These arterial blood gases indicate metabolic alkalosis.
B. INCORRECT: These arterial blood gases indicate metabolic alkalosis.
C. CORRECT: An aspirin overdose would result in arterial blood gas findings of metabolic acidosis.
D. INCORRECT: These arterial blood gases indicate respiratory alkalosis.
NCLEX® Connection: Reduction of Risk Potential, Laboratory values
2. A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and
difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are
obtained. Which of the following findings should the nurse expect?
A. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L
B. pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L Correct Answer: 2. A. CORRECT: A
pneumothorax can cause alveolar hyperventilation and increased carbon dioxide levels, resulting in a
state of respiratory acidosis.
B. INCORRECT: Arterial blood gases reflecting respiratory acidosis is not indicated for this client.
C. INCORRECT: Arterial blood gases reflecting metabolic acidosis is not indicated for this client.
D. INCORRECT: Arterial blood gases reflecting metabolic alkalosis is not indicated for this client.
NCLEX® Connection: Reduction of Risk Potential, Laboratory values
3. A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based
on the laboratory findings, which of the following conditions should the nurse expect?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis Correct Answer: 3. A. INCORRECT: Respiratory acidosis would not be indicated for
this client.
B. INCORRECT: Respiratory alkalosis would not be indicated for this client.
C. INCORRECT: Metabolic acidosis would not be indicated for this client.
D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the
blood, resulting in metabolic alkalosis.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte imbalances
4. A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the
following statements by the new nurse indicates the teaching has been effective?
A. "Metabolic acidosis can occur due to diabetic ketoacidosis."
B. "Metabolic acidosis can occur in a client who has myasthenia gravis."
C. "Metabolic acidosis can occur in a client who has asthma."
D. "Metabolic acidosis can occur due to cancer." Correct Answer: 4. A. CORRECT: Metabolic acidosis
results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.
B. INCORRECT: Respiratory acidosis can occur in a client who has myasthenia gravis.
1. A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the
client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations
24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated
with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit?
(Select all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea Correct Answer: 1. A. CORRECT: Decreased skin turgor is a clinical manifestation present
with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results
in dryness of the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is
concentrated due to urinary output being decreased.
C. INCORRECT: Bradycardia is not a clinical manifestation present with fluid volume deficit.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade
fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
2. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2
lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal
cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness Correct Answer: 2. A. CORRECT: Dyspnea is a clinical manifestation present with fluid
volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is
struggling to breathe to obtain oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the
excess of fluid within the body. Weight gain can be a result of edema.
C. INCORRECT: Bradycardia is not a clinical manifestation related to fluid volume excess.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due to
the excess fluid that is retained, which depletes energy and increases the workload for the body.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
,3. A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should
the nurse assess for that is indicative of fluid volume deficit?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia Correct Answer: 3. A. INCORRECT: Moist skin is a clinical manifestation indicative of fluid
volume excess.
B. INCORRECT: Distended neck veins is a clinical manifestation indicative of fluid volume excess.
C. INCORRECT: Increased urinary output is a clinical manifestation indicative of fluid volume excess.
D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of
fluid volume deficit.
4. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and
confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C
(100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb
and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with
diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake.
B. Observe for signs of hypertension.
C. Encourage the client to ambulate to promote oxygenation.
D. Monitor respirations for shortness of breath. Correct Answer: 4. A. INCORRECT: The nurse should not
initiate fluid restrictions to limit intake. This would be an appropriate action for a client who has fluid
volume excess. The client is dehydrated, and fluids should be encouraged.
B. INCORRECT: The nurse should not be monitoring for signs of hypertension. This would be an
appropriate action for a client who has fluid volume excess. The client is hypotensive due to fluid volume
depletion. The nurse should monitor the client for hypotension.
C. INCORRECT: The nurse should not encourage the client to ambulate to promote oxygenation. This
would be an appropriate action for a client who has fluid volume excess. The client is experiencing
dizziness due to dehydration and is at risk for falling. The nurse should keep the client in bed and assist
him to the bathroom as needed.
D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for
shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right
lower lobe. This client is dehydrated and has fluid volume deficit.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte Imbalances
5. A nurse is planning caring for a client who is experiencing fluid volume excess. Which nursing actions
should the nurse include in the plan of care? Describe three interventions the nurse should take. Correct
Answer: 5. Check ABGs, SaO2, CBC, and chest x-ray results. ◯ Position the client in a semi-Fowler's
position. ◯ Obtain daily weight. ◯ Monitor intake and output. ◯ Administer supplemental oxygen as
prescribed. ◯ Reduce IV flow rates. ◯ Administer diuretics (osmotic, loop) as prescribed. ◯ Limit
fluid and sodium intake as prescribed. ◯ Monitor and document presence of edema (pretibial, sacral,
periorbital). ◯ Reposition the client at least every 2 hr. ◯ Support arms and legs to decrease
dependent edema as appropriate. ◯ Monitor vital signs and heart rhythm. ◯ Auscultate lung sounds
(listen for crackles).
,1. A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L.
Which of the following treatments can result in these laboratory findings?
A. Three tap water enemas
B. 0.9% sodium chloride solution IV at 50 mL/hr
C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
D. Administration of glucocorticoids Correct Answer: 1. A. CORRECT: Receiving three tap water enemas
can result in a decrease in serum sodium and potassium in the client. Tap water is hypotonic, and
gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.
B. INCORRECT: Receiving 0.9% sodium chloride solution IV at 50 mL/hr would not produce these results.
C. INCORRECT: Receiving 5% dextrose in water solution with 20 mEq of K+ at 80 mL/hr would not
produce these results.
D. INCORRECT: Receiving glucocorticoids would not produce these results.
3. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The
nurse should monitor for which of the following electrolyte imbalances?
A. Hypercalcemia
B. Hyponatremia
C. Hyperphosphatemia
D. Hypomagnesemia Correct Answer: 3. A. INCORRECT: An increase in calcium is not indicated with
nasogastric losses due to suctioning.
B. CORRECT: The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and
contain sodium.
C. INCORRECT: An increase in phosphatemia is not indicated with nasogastric losses due to suctioning.
D. INCORRECT: A decrease in magnesium is not indicated with nasogastric losses due to suctioning
4. A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse
use to perform this test?
A. Apply a blood pressure cuff to the client's arm.
B. Place the stethoscope bell over the client's carotid artery.
C. Tap lightly on the client's cheek.
D. Ask the client to lower his chin to his chest. Correct Answer: 4. A. INCORRECT: This is performed to
assess for Trousseau's sign.
B. INCORRECT: This is performed to auscultate a carotid bruit.
C. CORRECT: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to
elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this
side of his face.
D. INCORRECT: This is performed to assess for range of motion of the neck.
1. A nurse is caring for a client admitted with confusion and lethargy. The client was found at home
unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of
104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and
deep. Which of the following arterial blood gases findings should the nurse expect?
A. pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 24 mEq/L
, B. pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L Correct Answer: 1. A. INCORRECT:
These arterial blood gases indicate metabolic alkalosis.
B. INCORRECT: These arterial blood gases indicate metabolic alkalosis.
C. CORRECT: An aspirin overdose would result in arterial blood gas findings of metabolic acidosis.
D. INCORRECT: These arterial blood gases indicate respiratory alkalosis.
NCLEX® Connection: Reduction of Risk Potential, Laboratory values
2. A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and
difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are
obtained. Which of the following findings should the nurse expect?
A. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L
B. pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L Correct Answer: 2. A. CORRECT: A
pneumothorax can cause alveolar hyperventilation and increased carbon dioxide levels, resulting in a
state of respiratory acidosis.
B. INCORRECT: Arterial blood gases reflecting respiratory acidosis is not indicated for this client.
C. INCORRECT: Arterial blood gases reflecting metabolic acidosis is not indicated for this client.
D. INCORRECT: Arterial blood gases reflecting metabolic alkalosis is not indicated for this client.
NCLEX® Connection: Reduction of Risk Potential, Laboratory values
3. A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based
on the laboratory findings, which of the following conditions should the nurse expect?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis Correct Answer: 3. A. INCORRECT: Respiratory acidosis would not be indicated for
this client.
B. INCORRECT: Respiratory alkalosis would not be indicated for this client.
C. INCORRECT: Metabolic acidosis would not be indicated for this client.
D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the
blood, resulting in metabolic alkalosis.
NCLEX® Connection: Physiological Adaptations, Fluid and Electrolyte imbalances
4. A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the
following statements by the new nurse indicates the teaching has been effective?
A. "Metabolic acidosis can occur due to diabetic ketoacidosis."
B. "Metabolic acidosis can occur in a client who has myasthenia gravis."
C. "Metabolic acidosis can occur in a client who has asthma."
D. "Metabolic acidosis can occur due to cancer." Correct Answer: 4. A. CORRECT: Metabolic acidosis
results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.
B. INCORRECT: Respiratory acidosis can occur in a client who has myasthenia gravis.
