ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
A nurse assesses the rectal temperature of a patient who is postoperative following oral surgery. What patient assessment needs to be made before taking this temperature?
Correct Answer: C
Rationale: Postoperative patients require careful assessment before rectal temperature measurement due to potential risks. Platelet count is critical because low platelets (thrombocytopenia) increase bleeding risk from rectal trauma, a concern after any surgery, even oral. Pain assessment is important but not specific to rectal contraindications unless related to rectal discomfort, which isn't indicated here. Pulse rate monitoring doesn't directly impact rectal temperature safety unless cardiac issues (e.g., post-MI) are present, which isn't the case. A fecal occult blood test detects bleeding but isn't a pre-measurement necessity. Choice C is correct as it addresses a key contraindication—bleeding risk—ensuring patient safety. This reflects nursing judgment in evaluating hematologic status before invasive temperature methods, especially post-surgery.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the artery.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.