ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's abdomen and notes that the patient has a firm, non-tender mass. What is the next step in the assessment?
Correct Answer: D
Rationale: The correct answer is D: Refer the patient for imaging. When a nurse encounters a firm, non-tender mass in the abdomen, it is important to proceed with imaging to determine the nature of the mass. Imaging studies such as ultrasound, CT scan, or MRI can provide valuable information about the size, location, and characteristics of the mass. This step is crucial in identifying the potential underlying causes of the mass, such as tumors, cysts, or other abnormalities. Option A is incorrect because percussion is not typically used to assess for fluid in a mass. Option B is incorrect as palpation may not be safe if the mass is suspected to be malignant. Option C is incorrect as auscultation for bowel sounds may not provide relevant information about the mass. The best course of action is to refer the patient for imaging to further evaluate the mass accurately.
Question 2 of 5
The nurse is assessing a patient's heart sounds and notes that the patient has a S3 heart sound. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. An S3 heart sound is often indicative of volume overload and impaired ventricular function, both of which are common in heart failure. The S3 sound occurs in early diastole when the ventricle is rapidly filling. In contrast, choices B, C, and D are not typically associated with S3 heart sounds. Mitral valve regurgitation causes a murmur, aortic stenosis causes a systolic murmur, and pulmonary embolism does not typically produce S3 heart sounds.
Question 3 of 5
96.0 to 99.5 degrees Fahrenheit is the normal temperature range of which age group?
Correct Answer: C
Rationale: Neonate, is correct because the normal body temperature range for newborns (birth to 28 days) is approximately 96.0°F to 99.5°F, depending on measurement site (e.g., axillary). Neonates have immature thermoregulation, leading to a slightly wider and lower range than adults. Toddler (1-3 years), typically has a range closer to 97.5°F-100.4°F. Adolescent, aligns with adult norms (97°F-99°F). Middle adult, also falls within 97°F-99°F, narrower than the neonate range. Neonates susceptibility to environmental changes and less efficient hypothalamus function explain this broader range. Clinical practice confirms 96.0°F-99.5°F as typical for neonates, especially in controlled settings like nurseries, making C the accurate answer based on pediatric physiology.
Question 4 of 5
The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated?
Correct Answer: C
Rationale: Rectal temperature measurement is contraindicated in specific cases due to risks. For a newborn with hypothermia , its avoided due to fragile rectal tissue and potential perforation risk. A child with pneumonia has no specific rectal contraindication unless diarrhea is present, which isnt mentioned. An older adult post-myocardial infarction is at risk because thermometer insertion can stimulate the vagus nerve, slowing the heart rate, which is dangerous post-MI. A teenager with leukemia may have neutropenia, making rectal measurement risky due to infection potential from low white blood cell counts. Choice C is highlighted as correct in the context, supported by the vagus nerve risk. Other contraindications like rectal surgery or low platelets also apply but align with Cs cardiac focus here. This reflects nursing judgment in prioritizing patient safety based on physiological risks.
Question 5 of 5
A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent?
Correct Answer: B
Rationale: In pulse documentation, 3+ indicates amplitude (strength) on a 0-4+ scale (0 absent, 1+ weak, 2+ normal, 3+ strong, 4+ bounding). Here, 85 is the rate, regular is rhythm, and equal across sites rules out deficit. Pulse rate is 85, not 3+. Pulse quality fits 3+, reflecting strength. Rhythm is described as regular, not 3+. Deficit isn't indicated. Choice B is correct, aligning with standard nursing terminology for pulse assessment, crucial for evaluating circulation.