ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
The nurse is assessing a patient's abdomen and detects a mass. What is the next step in the assessment?
Correct Answer: C
Rationale: The correct next step in assessing a detected abdominal mass is to palpate it for size and consistency. Palpation helps determine the characteristics of the mass, such as its shape, size, texture, and tenderness. This step provides crucial information for further evaluation and diagnosis. Auscultation for bowel sounds would not provide direct information about the mass. Percussion for tenderness may be uncomfortable and should be done after palpation. Referring the patient for imaging should come after a thorough physical examination and initial assessment of the mass.
Question 2 of 5
The nurse is assessing a patient's lungs and hears a harsh, grating sound during both inspiration and expiration. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Pleural friction rub. This sound occurs due to the rubbing together of inflamed pleural surfaces during both inspiration and expiration. It is typically heard in conditions such as pleurisy or pneumonia. Rhonchi (B) are low-pitched rattling sounds typically heard during expiration, wheezing (C) is a high-pitched musical sound heard during expiration, and pneumothorax (D) presents with decreased or absent breath sounds on the affected side, not a friction rub.
Question 3 of 5
Which of the following values for vital signs would the nurse address first?
Correct Answer: B
Rationale: Oxygen saturation of 89%, is correct because its the most urgent. Normal oxygen saturation is 95-100%; 89% indicates hypoxemia, risking tissue damage and requiring immediate intervention (e.g., oxygen therapy). Temperature of 99°F, is slightly elevated but not critical. Respirations of 28, is high (normal 12-20), but less acute without context like distress. BP 160/89, suggests stage 1 hypertension, concerning but not immediately life-threatening. Nurses prioritize airway, breathing, and circulation (ABCs); low oxygen saturation directly impairs oxygenation, making B the top priority for swift action to prevent complications like organ failure.
Question 4 of 5
A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:
Correct Answer: C
Rationale: In a blood pressure of 120/80 mmHg, 120 is the systolic pressure, the highest pressure on arterial walls during ventricular contraction . The diastolic (80) is the lowest pressure during relaxation . Pulse pressure is the difference , here 40 mmHg. The rhythmic distention describes the pulse, not a specific reading. Choice C is correct, reflecting the systolic phase of the cardiac cycle, a fundamental concept in vital sign interpretation.
Question 5 of 5
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse reflects cardiac response but isn't directly hypothalamic. Respirations may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.