ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 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. Itβs not more prone to injury, not necessarily the largest, and suspensory ligaments are distributed throughout the breast.
Question 2 of 5
The nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?
Correct Answer: A
Rationale: Visual accommodation involves pupil constriction when focusing on a near object, like a finger moving toward the nose, to adjust focus. Blinking is a light reflex, peripheral vision is unrelated, and dilation is incorrect.
Question 3 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: Unequal chest expansion is often caused by a lung obstruction or collapse, such as in pneumothorax or atelectasis, which prevents one side of the chest from expanding fully. Bulging intercostal spaces, obesity, and accessory muscle use do not directly cause unequal expansion.
Question 4 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.
Question 5 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.