ATI RN
PN Vital Signs Assessment Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove , ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.
Question 5 of 5
A Normal body temperature can range from...
Correct Answer: C
Rationale: Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C) orally , adjusting slightly by route (e.g., rectal +1°F, axillary -1°F). 95°F to 98°F includes hypothermia. 98°F to 105°F spans fever. 95°F to 100°F is too broad. Choice C is correct, reflecting standard ranges in nursing texts (e.g., Potter & Perry), critical for identifying normothermia versus deviations like fever or hypothermia.