ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger. Which aspect of neurological function is being tested?
Correct Answer: D
Rationale: The correct answer is D: Coordination and balance. When the nurse asks the patient to touch their nose with their finger, they are assessing the patient's ability to perform a coordinated movement accurately. This test specifically evaluates the patient's coordination and balance, as it involves the integration of sensory input and motor output. The cerebellum plays a crucial role in coordinating movements, making option A partially correct but not as specific as option D. Cranial nerve function (option B) is not directly assessed with this task. Proprioception (option C) refers to the awareness of the position and movement of the body, which is important for coordination but not the primary focus of this test.
Question 2 of 5
The nurse is assessing a patient for signs of heart failure. Which finding is most consistent with this condition?
Correct Answer: A
Rationale: The correct answer is A: Edema in the lower extremities. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the body, causing edema. Increased respiratory rate (B) may occur but is not specific to heart failure. Decreased blood pressure (C) and bounding pulse (D) are not typically seen in heart failure but may be present in other conditions. Edema is a classic sign of heart failure due to fluid retention from decreased cardiac output.
Question 3 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 4 of 5
A newborns temperature should be:
Correct Answer: C
Rationale: 37.7 degrees Celsius (rectal), is correct because newborns normal rectal temperature ranges from 36.6°C-38°C (97.9°F-100.4°F), with 37.7°C being typical. Oral (Choice A) isnt used in newborns due to safety and inaccuracy. 37°C axillary, is too low; axillary readings are 0.5°C-1°C below rectal (e.g., 36.5°C-37.2°C). 36.8°C axillary, fits axillary norms but isnt the questions focus. Rectal is the gold standard for neonates, reflecting core temperature despite their immature thermoregulation. Pediatric guidelines support 37.7°C as a common rectal value, making C the precise answer based on clinical practice.
Question 5 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.