ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the artery.
Correct Answer: B
Rationale: Brachial is best in infants for accessibility and strength. Radial is weak, femoral and popliteal less practical. Choice B is correct, per pediatric standards.
Question 2 of 5
During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?
Correct Answer: D
Rationale: 160/100 mmHg is hypertension; notifying the provider ensures evaluation. Rechecking is secondary. Documenting alone delays action. Meds without orders are unsafe. Choice D is correct, per the explanation, prioritizing escalation.
Question 3 of 5
While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patients respiratory rate is 8 breaths/min. How will the nurse interpret this finding?
Correct Answer: C
Rationale: Bradypnea at 8 breaths/min is a response to IICP, per the answer key, as pressure on the brainstem slows respiration (Cushing's triad). It's not uncommon , nor does IICP typically cause tachypnea . Normal is 12-20 (D incorrect). Nurses recognize this as a critical sign requiring urgent action.
Question 4 of 5
A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, I have had a lot of pain in my abdomen. What type of assessment would the nurse conduct?
Correct Answer: C
Rationale: A focused assessment , per the answer key, targets the new abdominal pain complaint, narrowing from the hip issue. Comprehensive covers all systems, ongoing partial tracks known conditions, and emergency is for acute crises. Nurses use focused assessments, per Taylor, to address specific symptoms efficiently in home settings.
Question 5 of 5
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?
Correct Answer: D
Rationale: Moisture in air passages , per the answer key, causes crackles (e.g., in pneumonia). Normal air , upper airway , or small passages produce different sounds. Nurses, per Taylor, recognize this for respiratory diagnosis.