ATI RN
ATI RN Custom Exams Set 3
1. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb’s point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct answer: A
Rationale: The correct answer is A: Second intercostal space, right sternal border. The aortic valve is best auscultated at the second intercostal space, right sternal border, where the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as they are not the recommended anatomical positions for auscultating the murmur of aortic stenosis.
2. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- A. Monitor daily hemoglobin and hematocrit values.
- B. Administer furosemide (Lasix) intravenously.
- C. Encourage the client to take deep breaths.
- D. Teach the client fall prevention measures.
Correct answer: Teach the client fall prevention measures.
Rationale:
3. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?
- A. Recent chest x-ray results
- B. Medication history
- C. Breath sounds
- D. Lab results
Correct answer: C
Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.
4. Which medication is used to reverse the effects of opioid overdose?
- A. Naloxone
- B. Epinephrine
- C. Atropine
- D. Lidocaine
Correct answer: A
Rationale: Naloxone is the correct answer. Naloxone is specifically used to reverse the effects of opioid overdose by binding to opioid receptors and blocking the effects of opioids. Epinephrine is mainly used to treat severe allergic reactions, Atropine is used for certain types of heart conditions and to reduce salivation or respiratory secretions, and Lidocaine is a local anesthetic used for numbing purposes. Therefore, choices B, C, and D are incorrect in the context of reversing opioid overdose.
5. When Baby Ian is held horizontally on his back, he sometimes makes an “embracing” motion by arching his back, extending his legs, throwing his arms outward, and then bringing his arms in toward his body. Ian is demonstrating the __________.
- A. palmar grasp
- B. Moro reflex
- C. tonic neck reflex
- D. Babinski reflex
Correct answer: B
Rationale: Baby Ian is demonstrating the Moro reflex. The Moro reflex is a normal newborn reflex that occurs when a baby feels like they are falling or losing support. It is characterized by arching the back, extending the legs, throwing the arms outward, and then bringing the arms in toward the body. This reflex is a primitive survival instinct that typically disappears around 6 months of age. Choice A, palmar grasp, involves the baby's fingers closing around an object when it touches their palm. Choice C, tonic neck reflex, involves the baby assuming a fencing position when their head is turned to one side. Choice D, Babinski reflex, is characterized by the fanning out and curling of the baby's toes when the sole of the foot is stroked.