ATI RN
Assess Vital Signs Questions
Question 1 of 5
A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 indicates potential shock or bleeding, a priority. Smoking or pain with stable BP is less urgent. Hypothermia needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.
Question 2 of 5
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is:
Correct Answer: C
Rationale: Nail polish, especially dark colors, blocks light transmission, interfering with pulse oximetry . It doesn't attract microbes , raise saturation , or generate heat . Choice C is correct, per nursing protocol ensuring accurate SpO2 readings by removing barriers to sensor function.
Question 3 of 5
The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?
Correct Answer: A
Rationale: Radial pulse requires two fingers on the thumb-side groove for accuracy. Thumb distorts. Light touch may miss weak pulses; strong pressure obliterates. Choice A is correct, per nursing technique.
Question 4 of 5
A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take?
Correct Answer: C
Rationale: A rate of 8 (below 12-20) suggests respiratory depression; assessing for distress is priority. It's not normal . Oxygen or bronchodilators need assessment first. Choice C is correct, per the explanation, ensuring nursing addresses potential respiratory compromise.
Question 5 of 5
A nurse is assessing a client's pain using a pain scale. Which pain scale is commonly used for children who are too young to verbalize their pain intensity?
Correct Answer: C
Rationale: FPS-R uses faces for non-verbal children to indicate pain. NRS and VAS need verbal skills. Wong-Baker is similar but less revised. Choice C is correct, per the explanation, suiting young children's needs.