ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?
Correct Answer: B
Rationale: Pleuritis causes a friction rub due to inflamed pleural layers rubbing during breathing. Wheezing, stridor, and crackles are associated with other conditions like asthma, upper airway obstruction, and fluid in the lungs, respectively.
Question 2 of 5
The nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which of the following cranial nerve should be assessed:
Correct Answer: C
Rationale: Cranial Nerve II (Optic Nerve) is responsible for vision, making it the nerve assessed during visual acuity testing. VI (Abducens) and III (Oculomotor) control eye movement, and V (Trigeminal) handles facial sensation and chewing.
Question 3 of 5
The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?
Correct Answer: A
Rationale: An extra sound late in diastole before S1 is the third heart sound (S3), often associated with heart failure due to rapid ventricular filling. S4 occurs earlier, friction rubs are pericardial, and split S2 involves valve closure timing.
Question 4 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: All options indicate potential respiratory or cardiovascular issues. Use of accessory muscles suggests respiratory distress. Nail bed clubbing (greater than 160 degrees) may indicate chronic hypoxia. Circumoral cyanosis reflects inadequate oxygenation. Pursed lip breathing can indicate respiratory difficulty, and a 1:1 anteroposterior-to-transverse diameter (barrel chest) is associated with COPD. All findings warrant reporting for further evaluation.
Question 5 of 5
The nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?
Correct Answer: A
Rationale: Visual accommodation involves pupil constriction when focusing on a near object, like a finger moving toward the nose, to adjust focus. Blinking is a light reflex, peripheral vision is unrelated, and dilation is incorrect.