ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A newborns temperature should be:
Correct Answer: C
Rationale: 37.7 degrees Celsius (rectal), is correct because newborns normal rectal temperature ranges from 36.6°C-38°C (97.9°F-100.4°F), with 37.7°C being typical. Oral (Choice A) isnt used in newborns due to safety and inaccuracy. 37°C axillary, is too low; axillary readings are 0.5°C-1°C below rectal (e.g., 36.5°C-37.2°C). 36.8°C axillary, fits axillary norms but isnt the questions focus. Rectal is the gold standard for neonates, reflecting core temperature despite their immature thermoregulation. Pediatric guidelines support 37.7°C as a common rectal value, making C the precise answer based on clinical practice.
Question 2 of 5
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8°F (36°C), whereas at 4:00 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?
Correct Answer: D
Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.
Question 3 of 5
The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
Vital signs are based on....
Correct Answer: C
Rationale: Vital signs reflect homeostasis , the body's ability to maintain internal stability (e.g., temperature, heart rate). Food processing affects digestion, not vital signs directly. Weight and height inform growth or BMI, not homeostasis monitoring. ‘None of the above' dismisses the correct link. Choice C is correct, as vital signs are physiological markers of homeostatic balance, a principle nurses use to assess health and guide care, per basic pathophysiology.
Question 5 of 5
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
Correct Answer: C
Rationale: Baseline vital signs provide a reference to assess current RR 26 and SpO2 92% against prior recovery, guiding interventions. Activity and meds inform care but not priority. Dyspnea perception is subjective, less critical than objective trends. Choice C is correct, per nursing process emphasizing baseline data for planning effective respiratory care.