ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
A nurse teaching a student nurse how to take temperatures with a nonmercury glass thermometer would be correct in stating the following:
Correct Answer: C
Rationale: Teaching nonmercury glass thermometer use involves technique precision. Wiping from fingers to bulb ensures cleanliness but risks contamination downward. Shaking to 92°F is incorrect; it should reset below 96°F. Reading horizontally at eye level with rotation is accurate for visibility, making it correct. Leaving it for 3 minutes varies by site (oral 3, rectal 2-3, axillary 5-10) and protocol, so it's imprecise. Choice C is best as it details a universal, correct reading method, critical for student learning and accurate temperature assessment in clinical practice.
Question 2 of 5
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
Hypothermia is defined as ...
Correct Answer: B
Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.
Question 4 of 5
Which of the following patients is most at risk for tachycardia?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.