ATI LPN
Nursing Vital Signs Practice Questions Questions
Question 1 of 5
A patient arrives at the outpatient clinic complaining of a headache. His face is flushed, and blood pressure is 170/88 mm Hg in the right arm and 188/92 mm Hg in the left arm. He reports that he ran out of blood pressure medication last week and has been unable to afford to refill the prescription. What is the nurse's priority nursing action?
Correct Answer: C
Rationale: The elevated BP (170/88 and 188/92 mm Hg) indicates a hypertensive urgency, especially given the patient’s history of missed medication. Notifying the health care provider is the priority to ensure rapid medical intervention (e.g., medication adjustment). Relaxation may lower BP slightly, but the values are too high to delay; financial assistance is secondary; cuff size adjustment is unlikely the issue given bilateral elevation.
Question 2 of 5
When measuring the patient's blood pressure, the following description is incorrect
Correct Answer: D
Rationale: Tucking the stethoscope chestpiece into the cuff (D) is incorrect; it should be placed under the cuff’s lower edge to hear Korotkoff sounds clearly. Resting (A), cuff placement (B), and fit (C) are correct techniques.
Question 3 of 5
A sterile field is contaminated if:
Correct Answer: D
Rationale: Unsterile contact breaks sterility. Nurse touch (A), gloved touch (B), or brief air exposure (C) doesn’t contaminate if sterile.
Question 4 of 5
A nurse's primary responsibility when administering a bed bath is to:
Correct Answer: B
Rationale: Dignity and comfort respect the patient. Speed (A), silence (C), or partial cleaning (D) compromises care.
Question 5 of 5
When performing mouth care on an unconscious patient, the nurse should:
Correct Answer: B
Rationale: Lateral positioning prevents aspiration during mouth care. Supine (A), toothbrushes (C), or no suction (D) risk choking.