ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?
Correct Answer: A
Rationale: Involuted, granular tonsils with deep crypts are normal in adults. The nurse should continue the assessment for other abnormalities. Referral, no response, or a throat culture is unnecessary without symptoms like sore throat or fever.
Question 2 of 5
The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:
Correct Answer: A
Rationale: The upper outer quadrant is the most common site for breast tumors due to its higher concentration of glandular tissue. It’s not more prone to injury, not necessarily the largest, and suspensory ligaments are distributed throughout the breast.
Question 3 of 5
A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?
Correct Answer: D
Rationale: The pupillary light reflex involves both pupils constricting in response to bright light to protect the retina. Convergence is a different reflex, focusing is unrelated to pupil size, and dilation in bright light is abnormal. No Light, Normal Response to Light, Positive RAPD of Right Eye, Stanford Medicine 25
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 examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?
Correct Answer: D
Rationale: A yellow or amber tympanic membrane suggests fluid or infection behind the eardrum, such as in otitis media, which is abnormal. A shiny, pearly white tympanic membrane, cerumen, and a cone of light are normal findings during an otoscopic exam.