ATI RN
Assessing Vital Signs Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse is assessing a client's radial pulse and finds it to be 50 beats per minute. What action should the nurse take?
Correct Answer: A
Rationale: A pulse of 50 can be normal, especially in fit individuals, and should be documented unless symptomatic. Monitoring is premature without distress. Tachycardia doesn't apply. Beta-blockers lower pulse, not needed here. Choice A is correct, per the explanation, reflecting nursing judgment based on context.
Question 5 of 5
A nurse is assessing a client's vital signs. Which vital sign reflects the number of times the heart beats per minute?
Correct Answer: C
Rationale: Heart rate measures beats per minute, assessing cardiac function. Respiratory rate counts breaths. BP is pressure, not rate. O2 sat is oxygenation percentage. Choice C is correct, per the explanation, a basic nursing concept.