ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
When assessing the lymph nodes, the nurse should: (select all that apply)
Correct Answer: B,C,D
Rationale: When assessing lymph nodes, the nurse should evaluate mobility, size, shape, and assess bilaterally to compare both sides for abnormalities. Unilateral assessment is not recommended as it may miss important findings on one side.
Question 2 of 5
The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client is experiencing a vision problem? (Select all that apply)
Correct Answer: B,E
Rationale: Pupils that remain dilated during an accommodation test indicate a potential issue with the autonomic nervous system, affecting pupil adjustment. Frowning and squinting while reading the Snellen chart suggest difficulty seeing clearly, indicating a vision problem. Normal findings, such as pupil dilation in dim light, 20/20 vision, and symmetrical pupillary reflex, do not indicate vision problems.
Question 3 of 5
The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Correct Answer: A,B
Rationale: When checking for edema in congestive heart failure, the nurse grades the edema on a scale of +1 to +4 based on the depth of pitting and presses the skin over the tibia to assess for pitting edema. Plantar flexing the feet is unrelated to edema assessment, and checking only one limb is insufficient as edema may occur bilaterally.
Question 4 of 5
When assessing the breast, the nurse would teach the patient to palpate which of the following areas?
Correct Answer: A,B,C
Rationale: The nurse should teach the patient to palpate all four quadrants of the breast (upper outer, lower inner, upper inner) and the tail of Spence, the extension of breast tissue into the axilla. This ensures a comprehensive self-examination to detect any abnormalities.
Question 5 of 5
The nurse auscultates the client's abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?
Correct Answer: B
Rationale: The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency. Listening for another minute is appropriate to confirm the absence of sounds. If no sounds are heard after additional time, auscultating for a total of 5 minutes or notifying the physician may be warranted. Listening posteriorly is not a standard practice for assessing bowel sounds.