ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse is assessing a patient's lungs and hears a low-pitched gurgling sound during inspiration. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Rhonchi. Rhonchi are low-pitched continuous lung sounds caused by airway secretions or mucus. They are typically heard during inspiration and expiration. Fine crackles (A) are high-pitched, discontinuous sounds caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound caused by narrowed airways. Pleural friction rub (D) is a grating sound heard during inspiration and expiration, caused by inflammation of the pleura. Therefore, the presence of low-pitched gurgling sounds during inspiration points towards rhonchi as the most likely cause.
Question 2 of 5
Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V.
Correct Answer: D
Rationale: Korotkoff sounds measure blood pressure. Phase I starts with faint tapping (systolic pressure). Phase II has muffled/swishing sounds with an auscultatory gap. Phase III features loud, clear sounds as the artery opens. Phase IV (E, not listed) muffles abruptly (first diastolic). Phase V ends with silence (second diastolic). Choice D is correct as it marks Phase I, the initial sound nurses identify as systolic pressure, critical for accurate blood pressure reading in clinical practice.
Question 3 of 5
A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children?
Correct Answer: A
Rationale: Pediatric blood pressure requires age-appropriate sites. Popliteal (A corrected from key's C) is used in infants or when arm access is limited, though brachial is standard for older children. Temporal isn't a BP site. Radial is for pulse. Choice A fits some pediatric contexts (e.g., neonates), per nursing texts, despite brachial's commonality.
Question 4 of 5
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 is normal with regular rhythm. Too fast or slow misaligns with norms. Toddler rates are lower (80-130). Choice A is correct, per pediatric vital sign standards.
Question 5 of 5
A heart rate measurement, or pulse, can be taken at which pulse point?
Correct Answer: D
Rationale: Pulse can be palpated at radial , brachial , dorsalis pedis , and other sites , depending on accessibility and need. All are valid, with radial most common, brachial for infants, and dorsalis pedis for circulation checks. Choice D is correct, per nursing assessment flexibility, allowing pulse detection across peripheral sites to monitor cardiac function.