ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer essential. A stethoscope assesses heart/lung sounds, not temperature. A blood pressure cuff or sphygmomanometer measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.
Question 2 of 5
The five primary vital signs routinely monitored by both caregivers and medical professionals and highlighted in this training, include the following:
Correct Answer: D
Rationale: The five primary vital signs are body temperature, blood pressure, heart rate (pulse), respiratory rate, and oxygen saturation . Weight and height/BMI (B, C) are additional metrics, not core vital signs. Choice D is correct, listing the standard set monitored in clinical practice, per nursing and medical guidelines (e.g., WHO, ANA), essential for comprehensive patient assessment and detecting acute changes.
Question 3 of 5
You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?
Correct Answer: D
Rationale: A too-narrow cuff overestimates BP. Past range (126/72–132/64) suggests 156/82 as falsely high, consistent with cuff error. 96/40 and 110/66 are too low. 130/70 fits prior range. Choice D is correct, per nursing principles on cuff size impacting accuracy, a common student mistake.
Question 4 of 5
The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's pulse.
Correct Answer: D
Rationale: Unresponsive, not breathing requires carotid pulse to assess central circulation. Peripheral sites (A, B, C) fail in arrest. Choice D is correct, per ACLS guidelines.
Question 5 of 5
A nurse is assessing a client's respiratory rate. Which technique should the nurse use to accurately measure the respiratory rate?
Correct Answer: A
Rationale: Visual chest observation is the standard, counting breaths per minute accurately. Auscultation assesses sound quality, not rate. Palpation isn't primary. Monitors are less common. Choice A is correct, per the explanation, reflecting nursing's practical approach to respiratory assessment.