ATI RN
Assess Vital Signs Questions
Question 1 of 5
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A. The significant change in blood pressure from 128/68 to 160/50, along with a significant decrease in pulse from 110 to 55, and a decrease in respirations from 26 to 14, indicates potential signs of deteriorating condition. A drop in blood pressure paired with a significant decrease in pulse and respirations could signify shock, which is a life-threatening condition that requires immediate intervention. Option B shows an increase in pulse and respirations, but the blood pressure remains within an acceptable range. Option C shows a slight increase in blood pressure with minimal changes in pulse and respirations. Option D shows a moderate decrease in pulse and a significant increase in respirations, but the blood pressure remains relatively stable. In summary, option A is the most concerning as it shows a combination of significant changes in blood pressure, pulse, and respirations, indicating a potential deterioration in the patient's condition.
Question 2 of 5
The nurse is performing a head-to-toe assessment. Which sequence of assessment techniques is correct for the abdominal region?
Correct Answer: C
Rationale: The correct sequence for assessing the abdominal region is inspection, auscultation, percussion, palpation (Choice C). Inspection allows visual assessment for any abnormalities. Auscultation should be done before palpation to prevent altering bowel sounds. Percussion helps assess for organ size and density. Palpation is done last to assess for tenderness, masses, and organ shape. Explanation for why the other choices are incorrect: A: Incorrect because palpation should be done after auscultation. B: Incorrect because auscultation should be done before palpation. D: Incorrect because palpation should be the last step in the sequence.
Question 3 of 5
During a cardiovascular assessment, the nurse auscultates a murmur. How should the nurse describe this finding?
Correct Answer: D
Rationale: The correct answer is D because a murmur is described as a whooshing or swishing sound heard over the heart due to turbulent blood flow. This sound is typically heard during systole or diastole, which aligns with the timing of heart sounds. A: A palpable vibration is more characteristic of a thrill, not a murmur. B: An extra heart sound refers to S3 or S4, not a murmur. C: A high-pitched sound during inspiration is more indicative of wheezing in the lungs, not a murmur.
Question 4 of 5
The nurse is palpating lymph nodes during an assessment. Which characteristic of lymph nodes is concerning?
Correct Answer: D
Rationale: The correct answer is D: Hard and fixed. This characteristic is concerning as it may indicate malignancy or infection. Normal lymph nodes should be soft, mobile, and non-tender. Hard and fixed lymph nodes can be a sign of abnormal growth or metastasis. It is important to monitor such nodes closely and further investigate any concerning findings to rule out serious conditions. Choices A, B, and C describe normal characteristics of lymph nodes and are not typically concerning during assessment.
Question 5 of 5
The nurse is auscultating the lungs and hears a high-pitched, musical sound on expiration. What does this sound indicate?
Correct Answer: A
Rationale: The correct answer is A: Wheezing. Wheezing is a high-pitched, musical sound on expiration caused by narrowing of airways. This indicates obstruction in the lower respiratory tract, commonly seen in conditions like asthma or COPD. Crackles (B) are discontinuous, crackling sounds heard on inspiration and indicate fluid in the alveoli. Pleural friction rub (C) is a grating, rubbing sound heard during inspiration and expiration, suggesting inflammation of the pleura. Stridor (D) is a high-pitched, harsh sound heard on inspiration, indicating upper airway obstruction.