ATI RN
ATI Fundamentals Assessment Exam Midterm Questions
Extract:
Question 1 of 5
In which disease process should a nurse expect to see a patient with the presence of pitting edema?
Correct Answer: B
Rationale: Liver disease, particularly cirrhosis, causes pitting edema due to low albumin levels reducing oncotic pressure and portal hypertension increasing fluid leakage. Diabetes and colon cancer do not directly cause pitting edema unless complicated by heart or kidney issues, and renal disease causes more generalized edema.
Question 2 of 5
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Correct Answer: D
Rationale: Stage II pressure ulcers involve partial-thickness skin loss, presenting as a shallow ulcer or blister with a red-pink wound bed, matching the description of erythema, serosanguineous drainage, and a blister-like appearance. Stage I has intact skin with non-blanchable redness, Stage III extends to subcutaneous tissue with a crater-like appearance, and Stage IV involves full-thickness loss with exposed bone or muscle.
Question 3 of 5
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Hypothyroidism causes weight gain due to slowed metabolism from low thyroid hormones. Palpitations, diaphoresis, and exophthalmos are associated with hyperthyroidism.
Question 4 of 5
While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?
Correct Answer: C
Rationale: Bronchovesicular sounds, medium-pitched and equal on inspiration and expiration, are normal in the 1st and 2nd intercostal spaces near the sternum. Rhonchi and crackles indicate pathology, and tracheal sounds are heard over the trachea.
Question 5 of 5
A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say 'ee,' and if the sound is heard as 'ay,' this is known as:
Correct Answer: D
Rationale: Egophony occurs when 'ee' is heard as 'ay' during auscultation, indicating lung consolidation (e.g., pneumonia). Bronchovesicular sounds are normal, bronchophony involves louder voice sounds, and normal resonance is muffled.