ATI Cardiovascular 3.0 Test Questions With
Correct Answers
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.
, A |nurse |is |assessing |a |client's |jugular |veins |and |carotid |arteries. |The |nurse |should |assist |the |
client |into |which |of |the |following |positions?
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.
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 |bilirubin |is |
released, |resulting |in |a |discoloration |of |the |skin |that |is |darker |than |surrounding |skin |tone.
Cool |skin |temperature |in |the |lower |leg |is |incorrect. |A |cool |skin |temperature |in |the |lower |leg |
is |a |finding |consistent |with |arterial |insufficiency |rather |than |peripheral |venous |disease.
Palpable |dorsalis |pedal |pulse |is |correct. |The |pedal |pulses |remain |present |in |clients |who |have |
peripheral |venous |disease. |Absent |pedal |pulses |are |consistent |with |arterial |insufficiency.
Bounding |dorsalis |pedal |pulse |is |incorrect. |A |bounding |dorsalis |pedis |pulse |is |not |a |consistent
|finding |with |venous |insufficiency. |In |venous |insufficiency |leading |to |a |venous |stasis |ulcer, |the |
leg |would |typically |be |edematous |and |have |a |pulse |that |is |difficult |to |palpate.
Pain |when |resting |is |incorrect. |Venous |statis |ulcers |are |not |associated |with |pain |when |resting.
A |nurse |is |auscultating |heart |sounds. |Identify |the |locations |the |nurse |should |listen |to |
determine |the |apical |pulse |rate. |(You |will |find |hot |spots |a=to |select |on |the |artwork |below. |
Select |only |the |hot |spot |that |corresponds |to |your |answer.)
D |is |correct. |
Rationale: |
This |area, |at |the |apex |of |the |heart, |is |where |sounds |generated |by |the |mitral |valve |between |
the |left |atrium |and |ventricle |are |best |heard |and |is |termed |the |apical |impulse |or |point |of |
maximal |impulse. |The |mitral |heart |sound |is |located |at |the |fifth |intercostal |space |in |the |left |
midclavicular |area. |The |nurse |should |auscultate |in |this |area |for |1 |min |to |determine |the |rate, |
rhythm |and |pitch |of |the |apical |pulse.
Correct Answers
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.
, A |nurse |is |assessing |a |client's |jugular |veins |and |carotid |arteries. |The |nurse |should |assist |the |
client |into |which |of |the |following |positions?
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.
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 |bilirubin |is |
released, |resulting |in |a |discoloration |of |the |skin |that |is |darker |than |surrounding |skin |tone.
Cool |skin |temperature |in |the |lower |leg |is |incorrect. |A |cool |skin |temperature |in |the |lower |leg |
is |a |finding |consistent |with |arterial |insufficiency |rather |than |peripheral |venous |disease.
Palpable |dorsalis |pedal |pulse |is |correct. |The |pedal |pulses |remain |present |in |clients |who |have |
peripheral |venous |disease. |Absent |pedal |pulses |are |consistent |with |arterial |insufficiency.
Bounding |dorsalis |pedal |pulse |is |incorrect. |A |bounding |dorsalis |pedis |pulse |is |not |a |consistent
|finding |with |venous |insufficiency. |In |venous |insufficiency |leading |to |a |venous |stasis |ulcer, |the |
leg |would |typically |be |edematous |and |have |a |pulse |that |is |difficult |to |palpate.
Pain |when |resting |is |incorrect. |Venous |statis |ulcers |are |not |associated |with |pain |when |resting.
A |nurse |is |auscultating |heart |sounds. |Identify |the |locations |the |nurse |should |listen |to |
determine |the |apical |pulse |rate. |(You |will |find |hot |spots |a=to |select |on |the |artwork |below. |
Select |only |the |hot |spot |that |corresponds |to |your |answer.)
D |is |correct. |
Rationale: |
This |area, |at |the |apex |of |the |heart, |is |where |sounds |generated |by |the |mitral |valve |between |
the |left |atrium |and |ventricle |are |best |heard |and |is |termed |the |apical |impulse |or |point |of |
maximal |impulse. |The |mitral |heart |sound |is |located |at |the |fifth |intercostal |space |in |the |left |
midclavicular |area. |The |nurse |should |auscultate |in |this |area |for |1 |min |to |determine |the |rate, |
rhythm |and |pitch |of |the |apical |pulse.
