ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
The patient complains of chest pains that move down her left arm. The nurse will document this as:
Correct Answer: B
Rationale: Radiating pain starts at a specific point and spreads to other areas, such as chest pain moving down the left arm, a common symptom of cardiac issues. Phantom pain occurs in absent limbs, referred pain is felt in a different area from the source, and somatic pain arises from skin, muscles, or bones.
Question 2 of 5
The nurse should utilize what type of precaution when palpating the lips in a healthy adult?
Correct Answer: C
Rationale: Standard precautions refer to the basic infection prevention measures that should be taken with all patients, regardless of their known or suspected infection status. This includes hand hygiene, the use of personal protective equipment (such as gloves), and the proper handling and disposal of contaminated items. Palpating the lips of a healthy adult does not require additional precautions unless an infection is suspected.
Question 3 of 5
Which of the following statements concerning breast examination is true?
Correct Answer: A
Rationale: Bimanual palpation is used to evaluate the tail of Spence, the breast tissue extending into the axilla. The axillae should always be palpated, nipple discharge is normal in pregnancy, and breasts are inspected in a consistent position to detect abnormalities.
Question 4 of 5
The nurse is teaching the patient about different stages of sleep. The nurse knows that REM sleep includes which one of the following?
Correct Answer: C
Rationale: REM (Rapid Eye Movement) sleep is a stage of sleep that is part of the sleep cycle, which also includes non-REM (NREM) sleep. Dreaming occurs during REM sleep, and it usually composes about 20-25% of total sleep time in adults. NREM sleep, on the other hand, makes up the largest amount of total sleep time, typically about 75-80%. Both REM and NREM sleep are important for restorative sleep, but each plays a different role in physiological and cognitive functioning.
Question 5 of 5
The nurse noted which of the following about the patient's skin during her monitoring assessment. (Select all that apply)
Correct Answer: B,C
Rationale: Skin assessment includes evaluating temperature (to detect illness or injury) and turgor (to assess hydration). Tachypnea is a respiratory rate finding, and tympany is a percussion sound, not related to skin assessment.