ATI RN
Vital Signs Health Assessment Questions
Question 1 of 5
According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, high blood pressure for adults is defined as...
Correct Answer: D
Rationale: NHLBI defines hypertension as 140 mmHg systolic or 90 mmHg diastolic , aligning with clinical standards (e.g., JNC 8). 120/80 is normal/prehypertension. 100/50 is low. 150/100 exceeds but isn't the threshold. Choice D is correct, reflecting NHLBI criteria nurses use to identify and manage high BP, a major cardiovascular risk factor.
Question 2 of 5
The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6°F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Place a nonadhesive sensor on the patient's ear lobe to quickly measure the patient's oxygen saturation. Placing the sensor on the ear lobe is essential because the patient has a latex allergy, and using a nonadhesive sensor helps prevent any allergic reactions. The ear lobe is an appropriate site for oxygen saturation monitoring as it provides a good blood flow and accurate readings. Option A) Attach a finger probe to the patient's index finger may not be suitable due to the risk of latex exposure from the probe. Option C) Attach a disposable adhesive sensor to the bridge of the patient's nose is not ideal as it may not provide accurate readings and can be uncomfortable for the patient. Option D) Place the sensor on the same arm that the electronic blood pressure cuff is on is not recommended as the cuff may interfere with the oxygen saturation sensor readings. Educationally, it is crucial for healthcare providers to understand the importance of selecting appropriate monitoring sites, especially in patients with specific allergies or conditions. Teaching proper assessment techniques and equipment selection ensures patient safety and accurate data collection in emergency situations. Additionally, reinforcing the significance of considering patient allergies when choosing medical devices is vital in providing quality and safe patient care.
Question 3 of 5
A nurse is assessing a client's body temperature and obtains a reading of 102°F (38.9°C). What action should the nurse take?
Correct Answer: B
Rationale: A temperature of 102°F (38.9°C) indicates fever but isn't immediately critical unless accompanied by severe symptoms. Documenting and monitoring allows tracking without overreaction. Antipyretics require orders and symptom context, not just one reading. Cool compresses offer comfort but don't address the cause. Notifying the provider is premature without additional concerns. Choice B is correct, per the explanation and nursing protocol, emphasizing observation over intervention for a moderate fever in stable patients.
Question 4 of 5
A nurse is assessing a client's oxygen saturation and obtains a reading of 92%. What action should the nurse take?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Initiate supplemental oxygen therapy. Oxygen saturation below 95% indicates hypoxemia, which is a condition where there is an inadequate amount of oxygen in the blood. Oxygen saturation of 92% is below the normal range (95-100%), and initiating supplemental oxygen therapy is crucial to ensure the client receives adequate oxygenation to meet the body's needs. Option A) Document the oxygen saturation as normal is incorrect because an oxygen saturation of 92% is below the normal range. Option B) Recheck the oxygen saturation in 30 minutes is not the best course of action as immediate intervention is needed when a client's oxygen saturation is below the normal range to prevent complications associated with hypoxemia. Option D) Instruct the client to perform deep breathing exercises is not appropriate in this situation as deep breathing exercises will not rapidly increase oxygen saturation to a safe level in cases of hypoxemia. Educationally, this scenario highlights the importance of prompt recognition and intervention for abnormal vital signs. Nurses must be able to interpret vital signs accurately and take appropriate actions to ensure patient safety and well-being. Understanding the significance of oxygen saturation levels is crucial in providing quality patient care and preventing adverse outcomes related to respiratory compromise.
Question 5 of 5
Which of the following is an average normal temperature in Centigrade for a healthy adult?
Correct Answer: A
Rationale: Oral 37.0°C is the average normal adult temperature, per the answer key, aligning with 98.6°F. Rectal is typically 0.5°C higher (37.5°C), axillary 0.5°C lower (36.5°C), and tympanic varies but isn't 34.4°C (too low). Oral is standard for its balance of accuracy and convenience, a nursing benchmark for assessing normothermia.