ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)
Correct Answer: C,D
Rationale: Blood pressure of 180/100 and respiratory rate of 32 indicate severe fluid overload, potentially leading to hypertension and pulmonary edema, requiring immediate intervention. Increased temperature and hematocrit are not typical, and heart rate of 120 bpm alone is less specific.
Question 2 of 5
The nurse is examining an adult client within normal weight limit. The nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?
Correct Answer: B
Rationale: Gynecomastia may result from hormonal imbalances, medications, or underlying conditions, so recommending a physician evaluation is appropriate. Assuming it’s benign, linking it to diet, or associating it with prostate enlargement without evidence is incorrect.
Question 3 of 5
The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?
Correct Answer: D
Rationale: The Snellen chart, positioned 20 feet away, is the standard for testing distance visual acuity. The confrontation test assesses peripheral vision, and Jaeger cards and newsprint test near vision.
Question 4 of 5
The nurse is preparing to assess the visual acuity of an adult patient, which of the following assessment should the nurse use for visual acuity
Correct Answer: D
Rationale: The Snellen chart at 20 feet is the standardized method for assessing distance visual acuity. The confrontation test evaluates peripheral vision, while Jaeger cards and newsprint assess near vision, not the primary focus of visual acuity testing.
Question 5 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: Visible use of accessory muscles during inhalation suggests that the client is working hard to breathe, which could indicate respiratory distress due to conditions like asthma or COPD. This is a concerning sign that requires prompt reporting for further evaluation and intervention. Clear and equal breath sounds bilaterally, oxygen saturation of 98% on room air, and a cough producing clear, thin sputum are normal findings and do not warrant immediate reporting.