ATI RN
Vital Signs Assessment Questions
Question 1 of 5
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
Correct Answer: A
Rationale: Temperature varies by route —e.g., rectal is 1°F higher, axillary 1°F lower than oral—requiring documentation for accuracy. Not all are core . Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
Question 2 of 5
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?
Correct Answer: C
Rationale: Bradycardia (pulse 44) with dizziness/fatigue requires apical pulse assessment to confirm rate and check for deficit, indicating cardiac output issues. Repeating radial delays RN evaluation. Stat ECG is secondary. Meds are premature. Choice C is correct, per nursing priority to verify and assess symptomatic bradycardia directly.
Question 3 of 5
While the nurse is assessing the patient's respirations, it is important for the patient to
Correct Answer: B
Rationale: Unawareness prevents altered breathing patterns. Awareness changes rate. Estimation isn't standard. No touch is impractical. Choice B is correct, per stealth assessment technique.
Question 4 of 5
A nurse is assessing a client's respiratory rate using a pulse oximeter. Where should the nurse place the pulse oximeter sensor to accurately measure the respiratory rate?
Correct Answer: A
Rationale: Pulse oximeters on the finger detect respiratory rate via blood volume changes tied to breathing cycles. Forehead , chest , and earlobe aren't standard for this. Choice A is correct, per the explanation, aligning with oximetry practice.
Question 5 of 5
A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?
Correct Answer: D
Rationale: 86% indicates severe hypoxemia, requiring immediate action. 95% is normal. 92% is mild, 89% significant but less urgent. Choice D is correct, per the explanation, reflecting nursing urgency for critical O2 levels.