Health Assessment Exam 2 ATI Practice
Questions
A nurse has completed a cardiovascular assessment on a client. Which of the
following findings should the nurse report to the provider?
A. Capillary refill of 3 seconds
B. +2 radial pulse
C. Fingernail with 160 degree curvature
D. Oxygen saturation 98% - ----ANS:Capillary refill of 3 seconds
A nurse is assessing a client who reports an increase in their stress level
related to the demands of their job. Which of the following interventions should
the nurse recommend for the client to reduce their stress?
A. Instruct the client to vary the time they go to sleep each night
B. Have the client check their BP daily
C. Discuss the benefits of meditation with the client
D. Have the client limit their exercise program until the stress has decreased -
----ANS:Discuss the benefits of meditation with the client
A nurse is assessing a client's jugular veins and carotid arteries. The nurse
should assist the client into which of the following positions?
A. Place the client in high- Fowler's position
B. Have the client lay supine with the head of their bed at a 45 degree angle
C. Have the client seated with their chin touching their chest
D. Place the client in a left lateral position - ----ANS:Have the client lay supine
with the head of their bed at a 45 degree angle
A nurse is assessing the anterior chest of a client. Which of the following
findings should the nurse report?
A. The point of maximal impulse (PMI) located at fifth intercostal space
B. Symmetrical chest movement during inhalation and expiration
C. Absent visible pulsations in the area of the point of maximal impulse (PMI)
, D. A forceful chest movement at the midclavicular line in the fourth intercostal
space - ----ANS:A forceful chest movement at the midclavicular line in the
fourth intercostal space
A nurse is auscultating a client's abdomen for the presence of bowel sounds.
Which of the following findings should the nurse expect for hypoactive bowel
sounds?
A. Bowel sounds absent after 5 min
B. Bowel sounds auscultated every 5 to 30 seconds
C. Bowel sounds auscultated every 3 seconds
D. Bowel sounds heard after 2 min - ----ANS:D. Bowel sounds heard after 2
min
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.) -
----ANS:1. Evaluate the head of the bed 30 degrees and instruct the client to
breath
2. Visualize the anatomy of the heart
3. Place the stethoscope to the right sternal border at the second intercostal
space
4. Place the stethoscope close to the sternal border at the fourth intercostal
space
5. Auscultate the apical pulse for 1 min
A nurse is auscultating heart sounds in a group of clients. Which of the
following should the nurse identify as an expected variation?
A. An adolescent who has an S3 heart sound
B. An older adult who has a heart rate of 48/min
C. A young adult who has an irregular apical pulse
D. A middle adult who has a murmur - ----ANS:A. An adolescent who has an
S3 heart sound
A nurse is auscultating heart sounds. Identify the location where the apical
pulse is auscultated.
A. 1st intercostal left
B. 1st intercostal right
C. 4th intercostal left
Questions
A nurse has completed a cardiovascular assessment on a client. Which of the
following findings should the nurse report to the provider?
A. Capillary refill of 3 seconds
B. +2 radial pulse
C. Fingernail with 160 degree curvature
D. Oxygen saturation 98% - ----ANS:Capillary refill of 3 seconds
A nurse is assessing a client who reports an increase in their stress level
related to the demands of their job. Which of the following interventions should
the nurse recommend for the client to reduce their stress?
A. Instruct the client to vary the time they go to sleep each night
B. Have the client check their BP daily
C. Discuss the benefits of meditation with the client
D. Have the client limit their exercise program until the stress has decreased -
----ANS:Discuss the benefits of meditation with the client
A nurse is assessing a client's jugular veins and carotid arteries. The nurse
should assist the client into which of the following positions?
A. Place the client in high- Fowler's position
B. Have the client lay supine with the head of their bed at a 45 degree angle
C. Have the client seated with their chin touching their chest
D. Place the client in a left lateral position - ----ANS:Have the client lay supine
with the head of their bed at a 45 degree angle
A nurse is assessing the anterior chest of a client. Which of the following
findings should the nurse report?
A. The point of maximal impulse (PMI) located at fifth intercostal space
B. Symmetrical chest movement during inhalation and expiration
C. Absent visible pulsations in the area of the point of maximal impulse (PMI)
, D. A forceful chest movement at the midclavicular line in the fourth intercostal
space - ----ANS:A forceful chest movement at the midclavicular line in the
fourth intercostal space
A nurse is auscultating a client's abdomen for the presence of bowel sounds.
Which of the following findings should the nurse expect for hypoactive bowel
sounds?
A. Bowel sounds absent after 5 min
B. Bowel sounds auscultated every 5 to 30 seconds
C. Bowel sounds auscultated every 3 seconds
D. Bowel sounds heard after 2 min - ----ANS:D. Bowel sounds heard after 2
min
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.) -
----ANS:1. Evaluate the head of the bed 30 degrees and instruct the client to
breath
2. Visualize the anatomy of the heart
3. Place the stethoscope to the right sternal border at the second intercostal
space
4. Place the stethoscope close to the sternal border at the fourth intercostal
space
5. Auscultate the apical pulse for 1 min
A nurse is auscultating heart sounds in a group of clients. Which of the
following should the nurse identify as an expected variation?
A. An adolescent who has an S3 heart sound
B. An older adult who has a heart rate of 48/min
C. A young adult who has an irregular apical pulse
D. A middle adult who has a murmur - ----ANS:A. An adolescent who has an
S3 heart sound
A nurse is auscultating heart sounds. Identify the location where the apical
pulse is auscultated.
A. 1st intercostal left
B. 1st intercostal right
C. 4th intercostal left
