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ATI Cardiovascular 3.0 Test Questions With Complete Solutions 2025

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ATI Cardiovascular 3.0 Test Questions With Complete Solutions 2025 A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report? - Correct Answer A forceful chest movement at the midclavicular line in the fourth intercostal space Rationale: A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is termed a heave or lift. This finding is associated with an enlarged left ventricle. This is an unexpected finding and should be reported to the provider. A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Correct Answer Rationale: Elevate the head of the bed 30° and instruct the client to breath normally is the first step. The nurse should instruct the client to breath normally and explain to them that they'll be listening to the heart in several places. The nurse should then position the client supine with the head of the bed elevated to a 30° angle. Visualize the anatomy of the heart is the second step. The nurse should visualize the anatomy of the heart as they auscultate to ensure they are listening in the correct area. Place the stethoscope to the right sternal border at the second intercostal space is the third step. The nurse should place the stethoscope to the right sternal border at the second intercostal space to begin auscultation of the aortic valve. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. This is the location for auscultation of the tricuspid valve. Auscultate the apical pulse for 1 min is the fifth step. The last heart sound is the mitral heart sound. This is where the apical pulse is heard and should be auscultated for 1 min to note rate, rhythm, and presence of the S1 heart sound. A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? - Correct Answer Have the client lay supine with the head of bed at a 30° angle. Rationale: Having the client positioned supine with the head of their bed at a 30° to 45° angle assists the nurse in visualizing the pulsation of the carotid arteries and the jugular vein. A nurse is caring for a client who has an ulceration on their ankle. Which of the following findings should the nurse identify as consistent with a venous stasis ulcer? Select all that apply. - Correct Answer Rationale: Skin color on the ankle that is darker than surrounding skin tone is correct. In venous insufficiency, the veins are unable to sufficiently return blood to the heart, resulting in blood pooling in the dependent extremity. As the blood pools, it breaks down and


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Subido en
11 de febrero de 2025
Número de páginas
5
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2024/2025
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