ATI RN
Assessing Vital Signs Questions
Question 1 of 5
Core temperatures are not measured at:
Correct Answer: D
Rationale: Sublingual site, is correct because it measures oral temperature, considered a surface reading, not a true core site. Core temperature reflects internal body heat (e.g., 98.6°F-100.4°F) and is taken at sites like Tympanic site (ear, near hypothalamus), Rectal site (most accurate), and Bladder (via catheter). Sublingual (under tongue) readings, while reliable, are slightly lower (~98.6°F) and influenced by air or food, making them non-core. Nursing distinguishes core for critical monitoring (e.g., hypothermia) versus surface for routine checks. Thus, D is the accurate choice, aligning with thermometry standards and physiological definitions.
Question 2 of 5
The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap conserves heat by covering this key area, a standard neonatal practice. A diaper alone offers minimal coverage, increasing heat loss. Doubling clothing helps but is less effective than a cap for head protection. Raising the room to 90°F risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
Question 3 of 5
A nurse is caring for a group of patients. Which patient will the nurse see first?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
Vital signs are measurements of...
Correct Answer: A
Rationale: Vital signs measure essential physiological functionstemperature, pulse, respiration, blood pressure, and oxygen saturationreflecting the body's basic operations . Urination frequency isn't a vital sign, though it's monitored in specific contexts. Weight and height are anthropometric, not vital signs. BMI is a calculated health indicator, not a direct measurement. Choice A is correct, aligning with nursing fundamentals defining vital signs as core indicators of life-sustaining processes, routinely assessed to evaluate health status and detect deviations requiring intervention.
Question 5 of 5
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
Correct Answer: A
Rationale: The 84-year-old with pneumonia, RR 28, SpO2 89% is priority due to hypoxemia and tachypnea, risking respiratory failure. BP 160/86 is elevated but stable. Temp 37.3°C is mild. RR 22, BP 148/62 is less acute. Choice A is correct, per ABC prioritization in nursing, addressing airway/breathing threats first.