ATI RN
Assessing Vital Signs Questions
Question 1 of 5
During a musculoskeletal assessment, the nurse notes that the patient has limited range of motion in the hip. What is the next step in the assessment?
Correct Answer: A
Rationale: The correct next step in this situation is to palpate the hip for tenderness. This is important to assess for any signs of inflammation, injury, or underlying musculoskeletal issues causing the limited range of motion. Palpation helps identify specific areas of discomfort or tenderness that may provide clues to the root cause of the limited range of motion. Performing passive range of motion (choice B) would be premature without first identifying any tenderness. Auscultating the joint for crepitus (choice C) is not necessary at this stage as it is more relevant in assessing joint sounds, not range of motion. Referring the patient for imaging (choice D) would be a later step after a more thorough assessment to confirm any suspected pathology.
Question 2 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 3 of 5
A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his mother's legs and asking to go home. Which of the following would be the best nursing intervention to accomplish this task?
Correct Answer: B
Rationale: A restless toddler clinging to the mother is likely anxious, making vital sign assessment challenging. Performing assessments with the child on the parent's lap provides comfort and stability, increasing cooperation and accuracy. Doing blood pressure first may heighten fear, as it involves a cuff that can feel restrictive, worsening the situation. Hiding instruments might reduce initial anxiety but doesn't address ongoing distress during measurement. Removing distractions could help focus but may not calm the child as effectively as parental presence. Choice B is best because it leverages the mother's comforting role, a proven pediatric nursing strategy to ease anxiety and facilitate procedures. This approach aligns with developmental considerations, prioritizing the child's emotional security to obtain reliable vital signs.
Question 4 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 5 of 5
A nurse is caring for a group of patients. Which patient will the nurse see first?
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler , adolescent , and adult values are normal for context. Choice A is correct, per triage prioritizing potential instability.