ATI RN
Health Assessment Vital Signs Quizlet Questions
Question 1 of 5
The nurse is auscultating the lungs and hears a pleural friction rub. What is the most likely cause of this finding?
Correct Answer: B
Rationale: The correct answer is B: Pleuritis. A pleural friction rub is caused by the inflammation of the pleural surfaces rubbing against each other during breathing. Pleuritis is the most likely cause as it directly involves inflammation of the pleura. Pneumonia (choice A) typically presents with crackles or decreased breath sounds. Pulmonary embolism (choice C) may present with pleuritic chest pain but not a friction rub. Chronic obstructive pulmonary disease (COPD) (choice D) is characterized by wheezing and decreased breath sounds, not a friction rub. Pleuritis is the only choice directly related to the inflammation of the pleura, leading to a pleural friction rub.
Question 2 of 5
During a cardiovascular assessment, the nurse notes that the patient has a rapid, irregular pulse. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Atrial fibrillation. A rapid, irregular pulse is a classic hallmark of atrial fibrillation, which is a common arrhythmia characterized by disorganized electrical activity in the atria. This leads to an irregular and often rapid ventricular response. Sinus arrhythmia (B) is a normal variation in heart rate associated with breathing and is typically regular. Ventricular tachycardia (C) is a life-threatening arrhythmia with a regular, fast heartbeat originating in the ventricles. Bradycardia (D) is a slow heart rate, which is the opposite of what is described in the question.
Question 3 of 5
Upon admission, the most appropriate person to check on a patients vital signs would be:
Correct Answer: A
Rationale: RN (Registered Nurse), is correct because upon admission, a comprehensive assessment, including vital signs, is typically performed by an RN due to their advanced training and scope of practice. RNs interpret data, identify abnormalities, and develop care plans, making them the most appropriate initial evaluator. LPN (Licensed Practical Nurse), assists with care but often works under RN supervision with a narrower scope. PCT (Patient Care Technician), and CNA (Certified Nursing Assistant), perform basic tasks like taking vital signs but lack the RNs authority to assess and act on findings independently upon admission. Hospital protocols prioritize RNs for initial assessments to ensure accuracy and timely intervention, especially in critical cases. Thus, A is the best choice, reflecting professional standards and patient safety priorities.
Question 4 of 5
A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits?
Correct Answer: D
Rationale: Normal vital signs vary by age. For a 4-month-old, a temperature of 38.1°C (100.5°F) is within the normal range of 37.1°C to 38.1°C (98.7°F to 100.5°F), making A correct. A 3-year-olds normal blood pressure is around 89/46 mmHg; 118/80 is elevated, so B is incorrect. A 9-year-olds temperature of 39°C (102.2°F) exceeds the normal range of 36.8°C to 37.8°C (98.2°F to 100°F), so C is incorrect. An adolescents pulse of 70 beats/min fits the normal range of 55 to 105, making D correct. Adults have a respiratory rate of 12 to 20 breaths/min, and older adults have a pulse of 40 to 100 beats/min, but these arent options here. Since this is a multiple-choice question with one answer listed as correct, D is the focus, supported by its alignment with age-specific norms.
Question 5 of 5
A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which of the following statements accurately describes a recommended guideline for using this type of equipment?
Correct Answer: A
Rationale: Cooling blankets manage fever effectively with proper use. Positioning with the top edge at the neck ensures full-body coverage, maximizing cooling, making it correct. A rectal probe for comatose patients is accurate but context-specific. Covering with a thick blanket insulates, counteracting cooling. Avoiding lanolin prevents interference but isn't a primary guideline. Choice A is best as it addresses placement, a fundamental step in hypothermia blanket protocols, ensuring efficient heat exchange per nursing standards.