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ATI RN 231 Quiz 4
Assessment 1 – Verified
Questions and Rationales
(2024/2025 Edition)
Patient Assessment (10 Questions)
1. A nurse is assessing a client with suspected dehydration. Which finding is most
indicative of fluid volume deficit?
A. Increased heart rate
B. Elevated blood pressure
C. Moist mucous membranes
D. Decreased skin turgor
Correct Answer: A. Increased heart rate
Rationale: Dehydration leads to decreased blood volume, causing tachycardia as the
heart compensates to maintain cardiac output. Elevated blood pressure is less common,
and moist mucous membranes suggest adequate hydration. Decreased skin turgor is a
sign but less specific than tachycardia.
2. During a respiratory assessment, the nurse notes a client’s respiratory rate is 28
breaths/min with shallow breathing. What should the nurse do first?
A. Administer oxygen via nasal cannula
B. Notify the provider immediately
C. Auscultate lung sounds bilaterally
D. Encourage deep breathing exercises
Correct Answer: C. Auscultate lung sounds bilaterally
Rationale: Auscultating lung sounds provides critical data to identify the cause of
tachypnea and shallow breathing, such as crackles or wheezing, before initiating
interventions or notifying the provider.
3. A client reports chest pain during a cardiac assessment. Which question should the
nurse ask first?
A. “Have you taken any medications today?”
B. “Can you describe the pain’s onset and duration?”
C. “Do you have a history of smoking?”
D. “Are you feeling anxious?”
Correct Answer: B. Can you describe the pain’s onset and duration?”
Rationale: Characterizing chest pain (onset, duration, quality) is critical to differentiate
between cardiac, respiratory, or other causes, guiding urgent interventions.
, 2
4. A nurse is performing a neurological assessment. Which finding indicates a
potential cranial nerve XII (hypoglossal) deficit?
A. Unequal pupil size
B. Tongue deviation to one side
C. Loss of smell
D. Difficulty hearing
Correct Answer: B. Tongue deviation to one side
Rationale: Cranial nerve XII controls tongue movement; deviation to one side on
protrusion suggests a deficit. Other options relate to different cranial nerves.
5. When assessing a client’s abdomen, which sequence should the nurse follow?
A. Palpation, inspection, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, palpation, percussion, inspection
D. Percussion, inspection, palpation, auscultation
Correct Answer: B. Inspection, auscultation, percussion, palpation
Rationale: This sequence prevents altering bowel sounds (auscultation) or causing
discomfort (palpation) before observing (inspection) and assessing (percussion).
6. A client with diabetes presents with confusion. What should the nurse assess first?
A. Blood glucose level
B. Blood pressure
C. Oxygen saturation
D. Temperature
Correct Answer: A. Blood glucose level
Rationale: Confusion in a diabetic client may indicate hypo- or hyperglycemia, making
blood glucose the priority assessment to guide immediate treatment.
7. During a skin assessment, the nurse notes a stage II pressure injury. What is the
defining characteristic?
A. Full-thickness skin loss with exposed subcutaneous tissue
B. Partial-thickness skin loss with a shallow open ulcer
C. Intact skin with non-blanchable redness
D. Exposed muscle or bone
Correct Answer: B. Partial-thickness skin loss with a shallow open ulcer
Rationale: Stage II pressure injuries involve partial-thickness skin loss, presenting as a
shallow ulcer or blister, per NPUAP guidelines.
8. A nurse is assessing a client’s peripheral pulses. Which finding indicates poor
perfusion?
A. 2+ pulses bilaterally
B. Warm, pink extremities
C. Weak, thready pulses
D. Capillary refill of 2 seconds
Correct Answer: C. Weak, thready pulses
Rationale: Weak, thready pulses suggest reduced blood flow and poor perfusion, unlike
normal (2+) pulses or other findings indicating adequate circulation.
9. A client reports shortness of breath. Which assessment finding requires immediate
intervention?
A. Respiratory rate of 18 breaths/min
ATI RN 231 Quiz 4
Assessment 1 – Verified
Questions and Rationales
(2024/2025 Edition)
Patient Assessment (10 Questions)
1. A nurse is assessing a client with suspected dehydration. Which finding is most
indicative of fluid volume deficit?
A. Increased heart rate
B. Elevated blood pressure
C. Moist mucous membranes
D. Decreased skin turgor
Correct Answer: A. Increased heart rate
Rationale: Dehydration leads to decreased blood volume, causing tachycardia as the
heart compensates to maintain cardiac output. Elevated blood pressure is less common,
and moist mucous membranes suggest adequate hydration. Decreased skin turgor is a
sign but less specific than tachycardia.
2. During a respiratory assessment, the nurse notes a client’s respiratory rate is 28
breaths/min with shallow breathing. What should the nurse do first?
A. Administer oxygen via nasal cannula
B. Notify the provider immediately
C. Auscultate lung sounds bilaterally
D. Encourage deep breathing exercises
Correct Answer: C. Auscultate lung sounds bilaterally
Rationale: Auscultating lung sounds provides critical data to identify the cause of
tachypnea and shallow breathing, such as crackles or wheezing, before initiating
interventions or notifying the provider.
3. A client reports chest pain during a cardiac assessment. Which question should the
nurse ask first?
A. “Have you taken any medications today?”
B. “Can you describe the pain’s onset and duration?”
C. “Do you have a history of smoking?”
D. “Are you feeling anxious?”
Correct Answer: B. Can you describe the pain’s onset and duration?”
Rationale: Characterizing chest pain (onset, duration, quality) is critical to differentiate
between cardiac, respiratory, or other causes, guiding urgent interventions.
, 2
4. A nurse is performing a neurological assessment. Which finding indicates a
potential cranial nerve XII (hypoglossal) deficit?
A. Unequal pupil size
B. Tongue deviation to one side
C. Loss of smell
D. Difficulty hearing
Correct Answer: B. Tongue deviation to one side
Rationale: Cranial nerve XII controls tongue movement; deviation to one side on
protrusion suggests a deficit. Other options relate to different cranial nerves.
5. When assessing a client’s abdomen, which sequence should the nurse follow?
A. Palpation, inspection, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, palpation, percussion, inspection
D. Percussion, inspection, palpation, auscultation
Correct Answer: B. Inspection, auscultation, percussion, palpation
Rationale: This sequence prevents altering bowel sounds (auscultation) or causing
discomfort (palpation) before observing (inspection) and assessing (percussion).
6. A client with diabetes presents with confusion. What should the nurse assess first?
A. Blood glucose level
B. Blood pressure
C. Oxygen saturation
D. Temperature
Correct Answer: A. Blood glucose level
Rationale: Confusion in a diabetic client may indicate hypo- or hyperglycemia, making
blood glucose the priority assessment to guide immediate treatment.
7. During a skin assessment, the nurse notes a stage II pressure injury. What is the
defining characteristic?
A. Full-thickness skin loss with exposed subcutaneous tissue
B. Partial-thickness skin loss with a shallow open ulcer
C. Intact skin with non-blanchable redness
D. Exposed muscle or bone
Correct Answer: B. Partial-thickness skin loss with a shallow open ulcer
Rationale: Stage II pressure injuries involve partial-thickness skin loss, presenting as a
shallow ulcer or blister, per NPUAP guidelines.
8. A nurse is assessing a client’s peripheral pulses. Which finding indicates poor
perfusion?
A. 2+ pulses bilaterally
B. Warm, pink extremities
C. Weak, thready pulses
D. Capillary refill of 2 seconds
Correct Answer: C. Weak, thready pulses
Rationale: Weak, thready pulses suggest reduced blood flow and poor perfusion, unlike
normal (2+) pulses or other findings indicating adequate circulation.
9. A client reports shortness of breath. Which assessment finding requires immediate
intervention?
A. Respiratory rate of 18 breaths/min
