ATI RN
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ATI RN Fundamentals Exam 2 Questions
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Question
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1 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: Inspection of the anterior chest includes observing the shape and configuration of the chest wall for abnormalities like asymmetry or deformities. Presence of breath sounds is assessed via auscultation, diaphragmatic excursion via percussion, and symmetric chest expansion via palpation and observation, not solely inspection.
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: Dysphagia, or difficulty swallowing, is commonly associated with stroke due to muscle weakness, including facial muscles. Facial drooping on one side, as seen in this client, indicates neurological impairment that can affect swallowing muscles. Xerostomia (dry mouth), epistaxis (nosebleed), and rhinorrhea (runny nose) are not directly related to stroke-induced facial drooping.
Question 3 of 5
A client comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The client also complains of dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this client has manifestations of:
Correct Answer: A
Rationale: The symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and pain in the cheeks and teeth suggest maxillary sinusitis, an inflammation of the maxillary sinuses. Nasal polyps cause congestion, frontal sinusitis causes forehead pain, and posterior epistaxis involves nosebleeds, not these symptoms.
Question 4 of 5
The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)
Correct Answer: C,D
Rationale: Blood pressure of 180/100 and respiratory rate of 32 indicate severe fluid overload, potentially leading to hypertension and pulmonary edema, requiring immediate intervention. Increased temperature and hematocrit are not typical, and heart rate of 120 bpm alone is less specific.
Question 5 of 5
The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?
Correct Answer: D
Rationale: Visible use of accessory muscles during inhalation suggests that the client is working hard to breathe, which could indicate respiratory distress due to conditions like asthma or COPD. This is a concerning sign that requires prompt reporting for further evaluation and intervention. Clear and equal breath sounds bilaterally, oxygen saturation of 98% on room air, and a cough producing clear, thin sputum are normal findings and do not warrant immediate reporting.