ATI Cardiovascular 3.0 Test –
Questions with Verified
Answers
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A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report?
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.)
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.
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