ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 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 apical pulse is located at the fifth left intercostal space at the midclavicular line, where the heartbeat is most audible. The other locations are not precise for assessing the apical pulse.
Question 2 of 5
A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
Correct Answer: C
Rationale: Placing the arm above heart level can falsely lower the blood pressure reading. The arm should be at heart level. Checking the gauge, centering the cuff, and wrapping it firmly are correct actions.
Question 3 of 5
The nurse is auscultating the lungs of an adult client. The nurse hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. The nurse recognizes that these breath sounds are:
Correct Answer: C
Rationale: Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration, longer on inspiration than expiration, and are considered normal in the peripheral lung fields like the posterior lower lobes. Bronchovesicular sounds (
Choice
A) are medium-pitched and typically heard over major bronchi, not peripheral lobes. Tracheal sounds (
Choice
B) are harsh and high-pitched, normal over the trachea but not in the lung periphery. Bronchial sounds (
Choice
D) are high-pitched and loud, normal over the trachea, but indicate abnormality if heard in peripheral lung fields.
Question 4 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 5 of 5
The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?
Correct Answer: D
Rationale: The Snellen chart, positioned 20 feet away, is the standard for testing distance visual acuity. The confrontation test assesses peripheral vision, and Jaeger cards and newsprint test near vision.