ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale: All options indicate potential respiratory or cardiovascular issues. Use of accessory muscles suggests respiratory distress. Nail bed clubbing (greater than 160 degrees) may indicate chronic hypoxia. Circumoral cyanosis reflects inadequate oxygenation. Pursed lip breathing can indicate respiratory difficulty, and a 1:1 anteroposterior-to-transverse diameter (barrel chest) is associated with COPD. All findings warrant reporting for further evaluation.
Question 2 of 5
A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?
Correct Answer: A
Rationale: The atrial kick refers to atrial contraction late in diastole, pushing additional blood into the ventricles before systole. It does not occur during systole, is not ventricular pressure, and is not typically felt as a palpitation.
Question 3 of 5
The nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which of the following cranial nerve should be assessed:
Correct Answer: C
Rationale: Cranial Nerve II (Optic Nerve) is responsible for vision, making it the nerve assessed during visual acuity testing. VI (Abducens) and III (Oculomotor) control eye movement, and V (Trigeminal) handles facial sensation and chewing.
Question 4 of 5
The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:
Correct Answer: D
Rationale: Placing hands sideways on the posterolateral chest wall at T9 or T10 allows the nurse to feel for bilateral chest expansion during inspiration, confirming symmetry. Percussion assesses underlying structures, inspection identifies deformities, and tactile fremitus (repeating 'ninety-nine') assesses lung density, not chest expansion.
Question 5 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.