ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?
Correct Answer: D
Rationale: The correct answer is D: Shape and configuration of the chest wall. This is important to assess for any abnormalities or deformities that could indicate underlying respiratory or cardiac issues. A: Presence of breath sounds is important but not specific to anterior chest assessment. B: Diaphragmatic excursion is assessed at the posterior chest. C: Symmetric chest expansion is assessed during breathing and not specific to the anterior chest. Overall, D is the most relevant choice for assessing the anterior chest comprehensively.
Question 4 of 5
The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct because it is normal for women to have slightly different breast sizes. This is due to variations in glandular tissue, fat distribution, and other factors. It is important for the nurse to reassure the client that this is common and not a cause for concern.
Choices B, C, and D are incorrect as they provide inaccurate information.
Choice B specifically mentions breastfeeding, which is not necessarily the cause of breast asymmetry.
Choice C mentions a sudden uneven increase in breast size, which is not normal.
Choice D is incorrect as breasts are not always perfectly symmetric in size.
Question 5 of 5
The nurse is listening to the heart sounds of a client. The nurse recognizes that the S2:
Correct Answer: D
Rationale: The correct answer is D: Is caused by the closure of the semilunar valves. S2 is the second heart sound heard during the cardiac cycle and is caused by the closure of the aortic and pulmonic (semilunar) valves at the end of systole. This closure prevents blood from flowing back into the ventricles. Understanding the timing and mechanism of S2 is crucial in assessing cardiac function.
Choices A, B, and C are incorrect because S2 does not indicate the beginning of diastole, coincide with the carotid artery pulse, or is louder than S1. It is important to differentiate the sounds of the heart to accurately assess the patient's condition.