ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
A physical therapist works with a patient who has a deep partial-thickness burn on the upper extremity. Which dressing would be MOST appropriate for this type of wound?
Correct Answer: B
Rationale: The correct answer is B: Silver sulfadiazine dressing. This choice is correct because silver sulfadiazine has antimicrobial properties that can help prevent infection in deep partial-thickness burns. It also provides a moist environment for wound healing. A: Hydrocolloid dressing is not ideal for deep partial-thickness burns as it may not provide enough antimicrobial protection. C: Gauze dressing with saline is not the best choice as it can dry out the wound and may not provide adequate protection against infection. D: Transparent film dressing is not suitable for deep partial-thickness burns as it does not provide the necessary antimicrobial properties and may not allow proper wound healing.
Question 2 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 3 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 4 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.
Question 5 of 5
During a respiratory assessment, the nurse notes that the patient is using their accessory muscles to breathe. What is the most likely cause?
Correct Answer: A
Rationale: The correct answer is A: Acute asthma exacerbation. When a patient is using accessory muscles to breathe, it indicates respiratory distress. In acute asthma exacerbation, airway constriction leads to difficulty breathing, causing the patient to use accessory muscles to aid in breathing. This is a characteristic feature of asthma exacerbation. Summary: - B: COPD is characterized by chronic airflow limitation, not typically associated with sudden use of accessory muscles. - C: Pneumothorax is a collapsed lung, which may cause shortness of breath but doesn't usually result in the use of accessory muscles. - D: Pulmonary embolism is a blockage in a pulmonary artery, which can lead to shortness of breath but doesn't typically cause the use of accessory muscles for breathing.