ATI RN
Chapter 12 Vital Signs Assessment Questions
Question 1 of 5
The nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
Correct Answer: B
Rationale: Light-headedness, irregular pulse, and a BP drop (100/72 from 113/80) suggest instability (e.g., arrhythmia). Notifying the provider ensures prompt evaluation. More pressure won't clarify irregularity. Dismissing symptoms or delaying risks deterioration. Choice B is correct, per nursing escalation protocols.
Question 2 of 5
You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?
Correct Answer: D
Rationale: A too-narrow cuff overestimates BP. Past range (126/72–132/64) suggests 156/82 as falsely high, consistent with cuff error. 96/40 and 110/66 are too low. 130/70 fits prior range. Choice D is correct, per nursing principles on cuff size impacting accuracy, a common student mistake.
Question 3 of 5
The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's pulse.
Correct Answer: D
Rationale: Unresponsive, not breathing requires carotid pulse to assess central circulation. Peripheral sites (A, B, C) fail in arrest. Choice D is correct, per ACLS guidelines.
Question 4 of 5
A nurse is assessing a client's respiratory rate. Which technique should the nurse use to accurately measure the respiratory rate?
Correct Answer: A
Rationale: Visual chest observation is the standard, counting breaths per minute accurately. Auscultation assesses sound quality, not rate. Palpation isn't primary. Monitors are less common. Choice A is correct, per the explanation, reflecting nursing's practical approach to respiratory assessment.
Question 5 of 5
A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?
Correct Answer: D
Rationale: 8 breaths per minute signals potential distress; a thorough assessment is first to guide care. Oxygen or position needs data. Waiting delays action. Choice D is correct, per the explanation, ensuring nursing prioritizes evaluation.