ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A physical therapist uses an incentive spirometer with a patient post-thoracic surgery. The PRIMARY purpose of this intervention is to:
Correct Answer: D
Rationale: The correct answer is D: Prevent pulmonary complications. Using an incentive spirometer post-thoracic surgery helps prevent atelectasis and pneumonia by promoting lung expansion, improving ventilation, and clearing secretions. This intervention aids in maintaining lung function and preventing respiratory complications. A: Promote relaxation - While using an incentive spirometer may induce relaxation as a side effect, the primary purpose is not relaxation but rather to prevent pulmonary complications. B: Improve inspiratory muscle strength - Although using an incentive spirometer can help improve inspiratory muscle strength, the primary purpose is to prevent pulmonary complications. C: Reduce pain during breathing - While using an incentive spirometer may indirectly reduce pain by promoting optimal lung function, the primary purpose is to prevent pulmonary complications.
Question 2 of 5
Which physical assessment finding is most consistent with dehydration?
Correct Answer: C
Rationale: The correct answer is C: Dry, cracked lips. Dehydration leads to decreased fluid volume in the body, causing dryness and cracking of the lips due to lack of moisture. Moist mucous membranes (choice A) are typically seen in hydrated individuals. Increased skin turgor (choice B) is a sign of dehydration, but dry, cracked lips are more specific. Bounding peripheral pulses (choice D) are associated with conditions like fluid overload or increased blood volume, not dehydration. Dry, cracked lips are a key indicator of dehydration due to the direct impact of fluid depletion on mucous membranes.
Question 3 of 5
The nurse is conducting a health assessment on a patient with suspected meningitis. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: The correct answer is B: Nuchal rigidity. This is because nuchal rigidity, or neck stiffness, is a classic sign of meningitis due to inflammation of the meninges. It is often accompanied by headache, fever, and altered mental status. The other choices are not typically associated with meningitis. A Babinski sign is indicative of upper motor neuron lesion, hyperactive deep tendon reflexes can be seen in conditions like hyperthyroidism or upper motor neuron disorders, and asymmetrical pupils could indicate a neurological deficit but are not specific to meningitis. Therefore, nuchal rigidity is the most consistent finding in a patient with suspected meningitis.
Question 4 of 5
During a pain assessment, the patient rates their pain as 8 on a scale of 0 to 10. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Administer prescribed pain medication. The priority action is to address the patient's pain to provide relief and improve comfort. Administering pain medication is essential to manage the patient's pain effectively. Reassessing the pain in 30 minutes (choice A) delays pain relief. Simply documenting the pain level as reported (choice C) without taking action does not address the patient's immediate needs. Applying a warm compress (choice D) may provide some comfort but does not directly address the pain intensity reported by the patient. Administering pain medication is the most appropriate and immediate action to address the patient's discomfort.
Question 5 of 5
The nurse is performing a cardiac assessment and hears a harsh, grating sound during both systole and diastole. What does this sound most likely indicate?
Correct Answer: C
Rationale: The correct answer is C: Pericardial friction rub. This sound is typically indicative of inflammation of the pericardial sac, causing the pericardial layers to rub against each other during both systole and diastole. This is a distinctive sound separate from murmurs. A and B are incorrect as they refer to murmurs which are typically heard during either systole (A) or diastole (B). D, mitral valve prolapse, would present with a mid-systolic click and late systolic murmur, not a continuous sound throughout the cardiac cycle like a pericardial friction rub.