ATI RN
Assessing Vital Signs Questions
Question 1 of 5
A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his mother's legs and asking to go home. Which of the following would be the best nursing intervention to accomplish this task?
Correct Answer: B
Rationale: A restless toddler clinging to the mother is likely anxious, making vital sign assessment challenging. Performing assessments with the child on the parent's lap provides comfort and stability, increasing cooperation and accuracy. Doing blood pressure first may heighten fear, as it involves a cuff that can feel restrictive, worsening the situation. Hiding instruments might reduce initial anxiety but doesn't address ongoing distress during measurement. Removing distractions could help focus but may not calm the child as effectively as parental presence. Choice B is best because it leverages the mother's comforting role, a proven pediatric nursing strategy to ease anxiety and facilitate procedures. This approach aligns with developmental considerations, prioritizing the child's emotional security to obtain reliable vital signs.
Question 2 of 5
A nurse is caring for a group of patients. Which patient will the nurse see first?
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler , adolescent , and adult values are normal for context. Choice A is correct, per triage prioritizing potential instability.
Question 3 of 5
Vital signs are measurements of...
Correct Answer: A
Rationale: Vital signs measure essential physiological functionstemperature, pulse, respiration, blood pressure, and oxygen saturationreflecting the body's basic operations . Urination frequency isn't a vital sign, though it's monitored in specific contexts. Weight and height are anthropometric, not vital signs. BMI is a calculated health indicator, not a direct measurement. Choice A is correct, aligning with nursing fundamentals defining vital signs as core indicators of life-sustaining processes, routinely assessed to evaluate health status and detect deviations requiring intervention.
Question 4 of 5
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
Correct Answer: A
Rationale: The 84-year-old with pneumonia, RR 28, SpO2 89% is priority due to hypoxemia and tachypnea, risking respiratory failure. BP 160/86 is elevated but stable. Temp 37.3°C is mild. RR 22, BP 148/62 is less acute. Choice A is correct, per ABC prioritization in nursing, addressing airway/breathing threats first.
Question 5 of 5
The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes?
Correct Answer: C
Rationale: Jaw/teeth injuries rule out oral . Axillary is less accurate in shock (cool, diaphoretic). Temporal may be affected by sweat. Rectal ensures core accuracy. Choice C is correct, per emergency nursing standards.