ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Recognize that this situation requires immediate intervention. If the nurse is unable to suction the nares and pass a catheter through, it suggests a potential blockage or obstruction in the nasal passages, which could lead to respiratory distress. Immediate intervention is crucial to ensure the newborn's airway is clear and breathing is not compromised. Contacting the physician or seeking further medical assistance promptly is necessary to address the issue. Choice A is incorrect because simply attempting to suction again may not resolve the underlying obstruction, and delaying necessary intervention could be harmful. Choice C is incorrect as scheduling an appointment for the infant at a later time is not appropriate when immediate intervention is required. Choice D is not applicable as it does not provide any solution or guidance for the current situation.
Question 2 of 5
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary consolidation. Bronchophony is a finding in which spoken words are heard distinctly and clearly through the stethoscope, indicating increased lung density. This is commonly seen in pulmonary consolidation, where air-filled lung tissue becomes filled with fluid or solid material. This can be caused by conditions such as pneumonia or lung tumors. Assessing for signs of pulmonary consolidation, such as increased tactile fremitus, dullness to percussion, and crackles on auscultation, is crucial. Choices A, B, and D are incorrect because bronchophony is not typically associated with these conditions. Airway obstruction, emphysema, and asthma have different characteristic auscultation findings and are not directly linked to bronchophony.
Question 3 of 5
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
Correct Answer: D
Rationale: Step 1: After menopause, hormonal changes lead to a decrease in estrogen levels. Step 2: Decreased estrogen causes glandular and fat tissue in the breasts to atrophy. Step 3: Atrophy of glandular and fat tissue results in diminished breast size and elasticity. Step 4: Diminished size and elasticity lead to breasts sagging. Step 5: Therefore, option D is correct as it accurately explains the physiological process behind breast sagging after menopause. Summary: Option A is incorrect as breast sagging can occur in women with any breast size. Option B is incorrect as breast sagging is not primarily due to decreased muscle mass. Option C is incorrect as protein intake does not directly prevent breast sagging caused by tissue atrophy.
Question 4 of 5
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?
Correct Answer: C
Rationale: The correct answer is C because BSE (Breast Self-Examination) on a monthly basis helps women become familiar with their breasts, enabling them to detect any abnormal changes early. This empowers women to seek timely medical help if needed, potentially improving outcomes. Choice A is incorrect as having children does not determine the importance of BSE. Choice B is incorrect as the statistic of one in nine women developing breast cancer does not directly relate to the importance of BSE. Choice D is incorrect because while BSE can help in early detection, it is not a guaranteed life-saving measure between mammograms.
Question 5 of 5
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?
Correct Answer: C
Rationale: The correct answer is C: No further response is needed because sinus arrhythmia can occur normally. Sinus arrhythmia is a common finding in young individuals, characterized by a variation in heart rate with respiration. In this case, the irregular rhythm of the apical pulse with speeding up on inspiration and slowing on expiration is consistent with sinus arrhythmia. It is a benign condition and does not require further intervention. Options A and D are incorrect as they are unnecessary and may cause unnecessary worry for the patient. Option B is also unnecessary at this point as the irregular rhythm is likely due to sinus arrhythmia and does not require immediate ECG confirmation.