ATI RN
Vital Signs Assessment ATI Quizlet Questions
Question 1 of 5
The nurse is assessing a patient's abdomen and notes the presence of visible peristalsis. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Gastrointestinal obstruction. Visible peristalsis indicates increased movement of the intestines in an attempt to overcome the obstruction. This finding is not associated with normal digestive function (choice A), ascites (choice C), or hernia (choice D). Gastrointestinal obstruction leads to visible peristalsis due to the intestines trying to push contents past the blockage. This assessment finding is crucial for prompt intervention to prevent complications.
Question 2 of 5
The nurse is performing an abdominal examination and detects a bruit over the aorta. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The presence of a bruit over the aorta during an abdominal examination is most likely associated with an Aortic Aneurysm. Aneurysms can cause turbulent blood flow resulting in a bruit. Aortic aneurysm is a common location for this finding due to the dilation of the aorta. Renal artery stenosis, pneumonia, and pancreatitis are not typically associated with a bruit over the aorta, making them incorrect choices.
Question 3 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 4 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 5 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.