ATI RN
Vital Signs Physical Assessment Techniques Questions
Question 1 of 5
During a cardiovascular assessment, the nurse notes that the patient has a jugular vein distension (JVD) when positioned at 45 degrees. What does this finding suggest?
Correct Answer: C
Rationale: The correct answer is C: Right-sided heart failure. Jugular vein distension (JVD) at 45 degrees indicates increased central venous pressure, commonly seen in right-sided heart failure. In this condition, the weakened right heart is unable to pump effectively, leading to venous congestion and JVD. Dehydration (B) typically presents with decreased jugular venous pressure. Pulmonary embolism (D) may cause JVD, but it's usually accompanied by other symptoms. JVD is not a normal finding (A) at 45 degrees and suggests an underlying pathology.
Question 2 of 5
Core body temperature is ___ surface body temperature.
Correct Answer: B
Rationale: Higher than, is correct because core body temperature (e.g., rectal, tympanic) is typically 0.5°F-1°F higher than surface temperature (e.g., oral, axillary) due to proximity to internal organs and less environmental influence. Core sites reflect true metabolic heat, averaging 98.6°F-100.4°F, while surface sites like skin average 97°F-99°F. Less than, reverses this fact. Equal to, ignores the gradient. None of the above, dismisses the clear difference. This distinction is vital in nursinge.g., rectal readings are higher and more stable than axillary, guiding fever assessment. Physiological principles and clinical tools (e.g., thermometers) confirm B as the correct answer.
Question 3 of 5
A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient?
Correct Answer: B
Rationale: IV fluids in the right arm interfere with accurate blood pressure measurement due to altered circulation and pressure. Taking it in the left arm avoids this, ensuring a reliable reading. Using the right arm risks inaccuracy. A small cuff doesnt address the IV issue and may overestimate pressure. Reporting inability is unnecessary when the left arm is viable. Choice B is correct, reflecting standard practice to use the unaffected limb.
Question 4 of 5
The patient has a temperature of 105.2°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction , transferring heat from the skin to the cooler objects through direct contact. Radiation involves heat loss to the environment without contact, not the primary method here. Convection requires air movement (e.g., fans), not used. Evaporation occurs with moisture vaporizing, a minor effect with tepid water but not dominant. Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.
Question 5 of 5
The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed?
Correct Answer: D
Rationale: For a 3-year-old, explaining the procedure reduces anxiety, improving cooperation. Diaphragm is less effective than the bell for Korotkoff sounds. Pre-settling risks agitation. Child cuff is correct but secondary. Choice D is correct, per pediatric nursing communication strategies.