ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is auscultating a patient's heart sounds and notes a high-pitched, blowing sound during systole. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: Aortic stenosis. This is indicated by a high-pitched, blowing sound during systole known as an ejection murmur. Aortic stenosis involves narrowing of the aortic valve, causing turbulent blood flow during systole. Mitral valve prolapse (B) presents with a mid-systolic click and late systolic murmur. Tricuspid regurgitation (C) results in a holosystolic murmur. Pulmonary regurgitation (D) typically presents with a diastolic murmur.
Question 2 of 5
A nurse assesses the rectal temperature of a patient who is postoperative following oral surgery. What patient assessment needs to be made before taking this temperature?
Correct Answer: C
Rationale: Postoperative patients require careful assessment before rectal temperature measurement due to potential risks. Platelet count is critical because low platelets (thrombocytopenia) increase bleeding risk from rectal trauma, a concern after any surgery, even oral. Pain assessment is important but not specific to rectal contraindications unless related to rectal discomfort, which isn't indicated here. Pulse rate monitoring doesn't directly impact rectal temperature safety unless cardiac issues (e.g., post-MI) are present, which isn't the case. A fecal occult blood test detects bleeding but isn't a pre-measurement necessity. Choice C is correct as it addresses a key contraindication—bleeding risk—ensuring patient safety. This reflects nursing judgment in evaluating hematologic status before invasive temperature methods, especially post-surgery.
Question 3 of 5
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8°F (36°C), whereas at 4:00 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?
Correct Answer: D
Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.
Question 4 of 5
The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
Correct Answer: B
Rationale: Portable BP devices require recalibration for accuracy, a key teaching point. Random cuff placement or arm movement skews readings. Stethoscopes aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.
Question 5 of 5
Vital signs are based on....
Correct Answer: C
Rationale: Vital signs reflect homeostasis , the body's ability to maintain internal stability (e.g., temperature, heart rate). Food processing affects digestion, not vital signs directly. Weight and height inform growth or BMI, not homeostasis monitoring. ‘None of the above' dismisses the correct link. Choice C is correct, as vital signs are physiological markers of homeostatic balance, a principle nurses use to assess health and guide care, per basic pathophysiology.