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 performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: A
Rationale: The frenulum is the tissue connecting the tongue to the floor of the mouth, aiding tongue movement. The palate is the mouthβs roof, the uvula hangs from the soft palate, and papillae are taste buds on the tongue.
Question 2 of 5
The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?
Correct Answer: A
Rationale: Slight asymmetry in breast size is a normal variation in many women and is not typically a cause for concern. Breastfeeding may cause temporary asymmetry, but not all asymmetry is due to this. Sudden uneven increases in size are not normal and require investigation, and perfect symmetry is rare.
Question 3 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 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 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.