ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Perform an otoscopic examination of the left nares. This is the correct next step to further assess the purulent drainage with a foul odor. By performing an otoscopic examination, the nurse can visualize the nasal passage and identify any underlying issues such as a possible foreign body, infection, or inflammation. It is important to rule out any potential serious conditions that may require medical intervention. Choice A is incorrect because antibiotics should not be prescribed without a proper assessment and diagnosis. Choice B is incorrect as waiting for a week can potentially lead to worsening of the condition. Choice D is incorrect as purulent drainage with a foul odor is not normal and should be further investigated.
Question 2 of 5
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
Correct Answer: A
Rationale: The correct answer is A: Wheezes. In severe asthma, narrowed bronchioles cause turbulent airflow, producing high-pitched wheezing sounds during expiration. These sounds are continuous, musical, and often heard without a stethoscope. Bronchial sounds (B) are normal breath sounds heard over the trachea, not indicative of asthma. Bronchophony (C) refers to increased vocal resonance and is not associated with bronchoconstriction. Whispered pectoriloquy (D) is a technique used to assess for consolidation in the lungs, not characteristic of asthma.
Question 3 of 5
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?
Correct Answer: B
Rationale: Answer B is correct because assessing the girl's weight and BMI is important to determine if early breast budding is related to precocious puberty, which can be influenced by weight. Option A is not appropriate as periods starting is not directly relevant to early breast development. Option C focuses on the mother's history, not the current girl's situation. Option D is incorrect as further evaluation is needed to rule out any underlying health issues.
Question 4 of 5
The direction of blood flow through the heart is best described by which of these?
Correct Answer: B
Rationale: The correct answer is B because it accurately describes the path of blood flow through the heart. Blood enters the right atrium from the vena cava, then goes to the right ventricle, gets pumped to the lungs through the pulmonary artery, returns to the heart from the lungs via the pulmonary vein, enters the left atrium, and finally flows to the left ventricle for systemic circulation. The other choices have inaccuracies in the sequence of chambers and blood vessels through which the blood flows, making them incorrect. Choice A has the pulmonary artery leading to the left atrium, which is incorrect. Choice C has the aorta before entering the right atrium, which is also incorrect. Choice D has the pulmonary vein leading to the pulmonary artery, which is incorrect.
Question 5 of 5
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
Correct Answer: D
Rationale: The correct answer is D because watching the patient's respirations while listening for the effect on the sound can help differentiate between an S3 and an opening snap or ejection sound. Observing how the sound changes with the respiratory cycle can provide valuable information about the origin and nature of the sound. Choice A is incorrect because having the patient turn to the left side with the bell of the stethoscope is typically done to enhance the detection of a mitral murmur, not to assess a sound immediately after S2. Choice B is incorrect because asking the patient to hold their breath is more relevant in assessing for a pericardial friction rub, not in differentiating between heart sounds. Choice C is incorrect because assuming the sound is an S3 without further assessment can lead to a misdiagnosis. It is essential to confirm the nature of the sound through appropriate assessment techniques.