ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:
Correct Answer: A
Rationale: The correct answer is A: When part of the lung is obstructed or collapsed. Unequal chest expansion can result from conditions such as pneumothorax, pleural effusion, or atelectasis, where part of the lung is obstructed or collapsed. This leads to decreased ventilation in that area and subsequently unequal chest expansion.
Choices B, C, and D are incorrect because bulging of intercostal spaces, obesity, and use of accessory muscles do not directly cause unequal chest expansion due to lung obstruction or collapse.
Question 2 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: The correct answer is D: A yellow or amber color to the tympanic membrane is considered an abnormal finding. The normal color of the tympanic membrane is pearly gray. A yellow or amber color may indicate infection or inflammation. A shiny, pearly white color (
A) is normal. The presence of cerumen (
B) is also normal as earwax is a natural substance. The presence of a cone of light (
C) is a normal finding caused by the reflection of light off the tympanic membrane. In summary, a yellow or amber color is abnormal, while the other choices represent normal findings during an otoscopic examination.
Question 3 of 5
The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:
Correct Answer: D
Rationale: The correct answer is D because placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10 allows the nurse to assess for symmetrical expansion during inhalation. This technique ensures that the nurse can feel and compare the movement of the chest wall bilaterally. By placing the hands at a specific level, the nurse can accurately detect any asymmetry in chest expansion, which may indicate underlying respiratory issues.
A: Percussion of the posterior chest is used to assess for lung density and air-filled structures, not chest expansion symmetry.
B: Inspection of the shape and configuration of the chest wall may provide information about chest abnormalities but does not directly confirm symmetric chest expansion.
C: Placing the palmar surface of the fingers against the chest and having the client repeat 'ninety nine' helps assess for tactile fremitus, not chest expansion symmetry.
Question 4 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: The correct answer is B. Gynecomastia in men can be caused by hormonal imbalances.
Therefore, it is important for the nurse to recommend that the client see his physician to investigate the underlying cause. This is the best course of action as it addresses the potential medical issue causing the gynecomastia.
Choice A is incorrect because while gynecomastia can be benign, it should not be assumed without further evaluation.
Choice C is incorrect as altering diet is not the appropriate response to gynecomastia.
Choice D is incorrect as gynecomastia is not usually associated with prostate enlargement, so recommending a thorough screening based on this assumption is unnecessary and potentially misleading.
Question 5 of 5
The nurse is preparing to assess the heart rate on an adult female client. The nurse recognizes that the apical pulse can be assessed in an adult female at which of the following anatomical position?
Correct Answer: A
Rationale: The correct answer is A: Fifth left intercostal space at the midclavicular line. The apical pulse is best assessed at the apex of the heart, which is located at the fifth intercostal space at the midclavicular line. This location allows for optimal auscultation of the heart sounds. Assessing the apical pulse at this position ensures accurate measurement of the heart rate.
Explanation for incorrect choices:
B: Third left intercostal space at the midclavicular line - This position is too high and does not correspond to the location of the apical pulse.
C: Fourth left intercostal space at the sternal border - This position is more associated with assessing the point of maximal impulse (PMI) rather than the apical pulse.
D: Under the left breast at the midclavicular line - This location is not typical for assessing the apical pulse and may lead to inaccurate readings.