ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 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 2 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 3 of 5
The nurse recognizes that the following statement is true regarding the internal structures of the breast: The breast is made up of:
Correct Answer: B
Rationale: The breast consists of fibrous tissue (Cooper’s ligaments for support), glandular tissue (for milk production), and adipose tissue (fat). Muscle is minimal, and milk ducts are part of glandular tissue, not the primary component.
Question 4 of 5
The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?
Correct Answer: C
Rationale: Palpating both carotid arteries simultaneously allows comparison of pulse amplitude, helping detect vascular abnormalities. Light observation, breath-holding, or showing the stethoscope diaphragm are not standard for carotid assessment.
Question 5 of 5
The nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from her findings?
Correct Answer: C
Rationale: Crepitus is a crackling sensation felt under the skin, often due to air in subcutaneous tissue. Friction rubs are heard or felt with pleural inflammation, tactile fremitus involves vibrations during speech, and adventitious sounds are abnormal lung sounds heard on auscultation.