ATI RN
ATI RN Fundamentals Exam 2 Questions
Question 1 of 5
The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?
Correct Answer: D
Rationale: The correct answer is D. Visible use of accessory muscles during inhalation indicates respiratory distress, requiring immediate attention. This finding suggests the client is having difficulty breathing efficiently. Reporting this to the practitioner is crucial to address the underlying cause promptly. A: Clear and equal breath sounds bilaterally are normal findings. B: Oxygen saturation of 98% on room air is within the normal range. C: Cough producing clear, thin sputum is indicative of a productive cough, which is a normal response to clear secretions.
Question 2 of 5
Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, and E.
A: Use of accessory muscles indicates respiratory distress.
B: Nail bed greater than 160 degrees can be a sign of poor perfusion.
C: Circumoral cyanosis suggests inadequate oxygenation.
D: Pursed lip breathing is a compensatory mechanism in respiratory distress.
E: Anteroposterior-to-transverse diameter of 1:1 indicates barrel chest, a sign of chronic obstructive pulmonary disease.
These findings are all critical indicators of respiratory distress and compromise, necessitating immediate reporting to the healthcare practitioner for prompt intervention.
Question 3 of 5
A group of nursing students are studying the conduction system of the heart. The nursing students should recognize that the pacemaker of the heart is known as
Correct Answer: A
Rationale: The correct answer is A: Sinoatrial node. The Sinoatrial (S
A) node is the natural pacemaker of the heart, generating electrical impulses to initiate the heartbeat. It is located in the right atrium and sets the rhythm for the heart. Other choices are incorrect as they do not serve as the primary pacemaker of the heart. The SA node is responsible for controlling the heart rate and ensuring proper coordination of contractions. It plays a crucial role in maintaining the heart's normal function and rhythm.
Question 4 of 5
The nurse is assessing the heart sounds of a client. The nurse understands that to listen to the pulmonic valve, the stethoscope should be placed where?
Correct Answer: C
Rationale: The correct answer is C: Second left intercostal space.
To listen to the pulmonic valve, the stethoscope should be placed at the second left intercostal space. This is because the pulmonic valve is best auscultated at the second left intercostal space along the sternal border. Placing the stethoscope at this specific location allows for optimal detection of the sounds produced by the pulmonic valve during the cardiac cycle. Placing the stethoscope at other locations, such as the fifth intercostal space, left of the midclavicular line (choice
A), left lower sternal border (choice
B), or second right intercostal space (choice
D), would not provide the best positioning for accurately assessing the pulmonic valve.
Therefore, choices A, B, and D are incorrect in this scenario.
Question 5 of 5
The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. When assessing a client with facial drooping after a stroke, the nurse should expect dysphagia due to the involvement of the cranial nerves responsible for swallowing. This is a common complication post-stroke. Xerostomia (
A) refers to dry mouth and is not directly related to facial drooping. Epistaxis (
B) refers to nosebleeds and is not typically associated with facial drooping. Rhinorrhea (
D) is nasal discharge and is not typically a direct consequence of facial drooping from a stroke.