ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 4
A nurse is assessing a client's pulse rate and finds it to be irregularly irregular with no discernible pattern. What action should the nurse take?
Correct Answer: C
Rationale: Irregularly irregular pulse suggests atrial fibrillation, requiring cardiac monitoring for confirmation. It's not normal . Waiting delays intervention. Breathing doesn't fix arrhythmias. Choice C is correct, per the explanation, aligning with nursing response to potential cardiac irregularities.
Question 2 of 4
While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patients respiratory rate is 8 breaths/min. How will the nurse interpret this finding?
Correct Answer: C
Rationale: Bradypnea at 8 breaths/min is a response to IICP, per the answer key, as pressure on the brainstem slows respiration (Cushing's triad). It's not uncommon , nor does IICP typically cause tachypnea . Normal is 12-20 (D incorrect). Nurses recognize this as a critical sign requiring urgent action.
Question 3 of 4
A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, I have had a lot of pain in my abdomen. What type of assessment would the nurse conduct?
Correct Answer: C
Rationale: A focused assessment , per the answer key, targets the new abdominal pain complaint, narrowing from the hip issue. Comprehensive covers all systems, ongoing partial tracks known conditions, and emergency is for acute crises. Nurses use focused assessments, per Taylor, to address specific symptoms efficiently in home settings.
Question 4 of 4
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?
Correct Answer: D
Rationale: Moisture in air passages , per the answer key, causes crackles (e.g., in pneumonia). Normal air , upper airway , or small passages produce different sounds. Nurses, per Taylor, recognize this for respiratory diagnosis.