ATI RN
Assess Vital Signs Rationale Questions
Question 1 of 5
During a respiratory assessment, the nurse notes that the patient has a prolonged inspiratory phase. What condition is most likely associated with this finding?
Correct Answer: D
Rationale: The correct answer is D: Upper airway obstruction. A prolonged inspiratory phase suggests difficulty with air intake, which is commonly seen in upper airway obstructions such as foreign body aspiration, croup, or epiglottitis. Asthma (A) typically presents with prolonged expiratory phase, COPD (B) with decreased expiratory phase, and pulmonary fibrosis (C) with decreased lung compliance and restrictive pattern, not affecting inspiratory phase.
Question 2 of 5
Which of the following controls the opening and closing of the arteriovenous shunts in response to changes in core body temperature and in environmental temperature?
Correct Answer: C
Rationale: Sympathetic nervous system, is correct as it regulates arteriovenous shuntsvessels linking arteries and veinsto control heat exchange. When cold, it constricts shunts, retaining heat; when hot, it dilates them, releasing heat. Autonomic nervous system, is broader (includes sympathetic and parasympathetic), but only sympathetic handles this. Parasympathetic, focuses on rest (e.g., digestion), not thermoregulation. All of the above, overextends. The sympathetic system, via norepinephrine, adjusts blood flow to skin, balancing core temperature (e.g., 98.6°F). Nursing notes this in pallor (cold) or flushing (heat). Thus, C is accurate per autonomic physiology.
Question 3 of 5
A nurse teaching a student nurse how to take temperatures with a nonmercury glass thermometer would be correct in stating the following:
Correct Answer: C
Rationale: Teaching nonmercury glass thermometer use involves technique precision. Wiping from fingers to bulb ensures cleanliness but risks contamination downward. Shaking to 92°F is incorrect; it should reset below 96°F. Reading horizontally at eye level with rotation is accurate for visibility, making it correct. Leaving it for 3 minutes varies by site (oral 3, rectal 2-3, axillary 5-10) and protocol, so it's imprecise. Choice C is best as it details a universal, correct reading method, critical for student learning and accurate temperature assessment in clinical practice.
Question 4 of 5
What is the primary purpose of pulse assessment?
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status , reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure relates but requires a cuff. Temperature isn't pulse-related. Respiratory status is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
Question 5 of 5
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 . Muffling (70) is phase IV, not standard for adults. 138/70 uses muffling incorrectly. 70/62 is invalid. 138/70/62 isn't standard. Choice B is correct, per AHA guidelines.