ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
The primary purpose of the ciliated mucous membrane in the nose is to:
Correct Answer: B
Rationale: The correct answer is B: Filter out dust and bacteria. The ciliated mucous membrane in the nose acts as a physical barrier to trap and remove harmful particles like dust and bacteria from the inhaled air. Here's the rationale: 1. The cilia trap particles: The cilia in the mucous membrane sweep back and forth, capturing dust and bacteria in the mucus. 2. Mucus removes particles: The sticky mucus traps the particles, preventing them from entering the respiratory system. 3. Prevents infections: By filtering out harmful particles, the mucous membrane helps protect the respiratory system from infections. 4. Other choices are incorrect: A is incorrect as the primary function is not to warm the air. C is incorrect as it focuses on coarse particles only. D is incorrect as it does not specifically address the filtration function of the mucous membrane.
Question 2 of 5
When assessing a patient's lungs, the nurse recalls that the left lung:
Correct Answer: A
Rationale: The correct answer is A: Consists of two lobes. The left lung indeed consists of two lobes - the upper lobe and the lower lobe, separated by the oblique fissure. The right lung, not the left lung, is divided by the horizontal fissure (B). The left lung primarily consists of the upper lobe on the anterior chest, not the posterior chest (C). The length of the lungs is not determined by the underlying organs like the stomach; it is mainly due to anatomical landmarks and structures. Therefore, option D is incorrect.
Question 3 of 5
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
Correct Answer: C
Rationale: Step 1: Bronchovesicular breath sounds are expected near the major airways. Step 2: Bronchovesicular sounds are heard over the 1st and 2nd intercostal spaces along the sternal border at the front and between the scapulae on the back. Step 3: The sounds are a combination of bronchial (heard over trachea and major bronchi) and vesicular (heard over peripheral lung fields) sounds. Step 4: The characteristics include moderate pitch and intensity, with equal inspiration and expiration. Step 5: Choice C is the correct answer as it accurately describes the expected location of bronchovesicular breath sounds near the major airways. Summary: A: Incorrect - Bronchovesicular breath sounds are not musical in quality. B: Incorrect - Bronchovesicular breath sounds are not usually caused by a pathologic disease. D: Incorrect - Bronchovesicular breath sounds are a combination of bronchial
Question 4 of 5
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?
Correct Answer: C
Rationale: The correct answer is C because gynecomastia in men is often caused by hormonal imbalances. By explaining this to the patient and recommending evaluation by a physician, the nurse ensures appropriate medical assessment and potential treatment. Choice A is incorrect because mammograms are not typically used to diagnose gynecomastia in men. Choice B is incorrect as gynecomastia should not be dismissed without further evaluation. Choice D is incorrect because gynecomastia is not always associated with prostate enlargement, and a thorough screening may not be necessary without more specific symptoms or risk factors.
Question 5 of 5
The sac that surrounds and protects the heart is called the:
Correct Answer: A
Rationale: The correct answer is A: Pericardium. The pericardium is the sac that surrounds and protects the heart. It consists of two layers - the outer fibrous pericardium and the inner serous pericardium. The fibrous pericardium provides structural support and protection, while the serous pericardium secretes fluid to reduce friction as the heart beats. Summary: B: Myocardium is the middle layer of the heart muscle responsible for pumping blood. C: Endocardium is the innermost layer of the heart lining the chambers and valves. D: Pleural space refers to the space between the lungs and the chest wall, not related to the heart.