ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Correct Answer: A,B
Rationale: When checking for edema in congestive heart failure, the nurse grades the edema on a scale of +1 to +4 based on the depth of pitting and presses the skin over the tibia to assess for pitting edema. Plantar flexing the feet is unrelated to edema assessment, and checking only one limb is insufficient as edema may occur bilaterally.
Question 2 of 5
When assessing the breast, the nurse would teach the patient to palpate which of the following areas?
Correct Answer: A,B,C
Rationale: The nurse should teach the patient to palpate all four quadrants of the breast (upper outer, lower inner, upper inner) and the tail of Spence, the extension of breast tissue into the axilla. This ensures a comprehensive self-examination to detect any abnormalities.
Question 3 of 5
The nurse auscultates the client's abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?
Correct Answer: B
Rationale: The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency. Listening for another minute is appropriate to confirm the absence of sounds. If no sounds are heard after additional time, auscultating for a total of 5 minutes or notifying the physician may be warranted. Listening posteriorly is not a standard practice for assessing bowel sounds.
Question 4 of 5
The nurse is mapping the client's abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)
Correct Answer: A
Rationale:
To map the abdomen into four quadrants, the nurse uses the umbilicus as the central landmark, drawing imaginary lines vertically and horizontally through it. The midclavicular lines, sternum, and lower border of the ribs are not used for this purpose.
Question 5 of 5
When assessing the patient's ability to perform rapid altering movements, the nurse is observing the:
Correct Answer: D
Rationale: The motor system controls voluntary movements, including rapid alternating movements like tapping fingers or rotating the wrist. Assessing these movements evaluates the coordination and integrity of the motor system, including muscles, nerves, and brain function.