ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing a respiratory assessment and hears crackles in the lower lung fields. What is the most likely cause of this finding?
Correct Answer: A
Rationale: The crackles heard in the lower lung fields suggest fluid accumulation, characteristic of pulmonary edema. This condition occurs when there is an excess of fluid in the lungs, often due to heart failure. Pneumothorax (choice B) involves air in the pleural space, not fluid. Asthma (choice C) and COPD (choice D) typically present with wheezing and airway obstruction, not crackles. Overall, crackles in the lower lung fields are most indicative of pulmonary edema.
Question 2 of 5
Which time of day would we have the lowest temperature reading?
Correct Answer: B
Rationale: 4 am to 6 am, is correct due to the bodys circadian rhythm, which lowers core temperature during early morning hours. Controlled by the hypothalamus, temperature dips to its lowest around 4-6 am (e.g., ~97°F) as metabolism slows during sleep. 4 pm to 6 pm, is near the daily peak (~98.6°F-100°F). 8 pm to 12 midnight, sees a decline but not the nadir. 1 am to 4 am, is close but precedes the lowest point. Studies show this pattern holds across healthy adults, reflecting natural thermoregulatory cycles, making B the precise answer for the lowest reading time.
Question 3 of 5
Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V.
Correct Answer: D
Rationale: Korotkoff sounds measure blood pressure. Phase I starts with faint tapping (systolic pressure). Phase II has muffled/swishing sounds with an auscultatory gap. Phase III features loud, clear sounds as the artery opens. Phase IV (E, not listed) muffles abruptly (first diastolic). Phase V ends with silence (second diastolic). Choice D is correct as it marks Phase I, the initial sound nurses identify as systolic pressure, critical for accurate blood pressure reading in clinical practice.
Question 4 of 5
A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children?
Correct Answer: A
Rationale: Pediatric blood pressure requires age-appropriate sites. Popliteal (A corrected from key's C) is used in infants or when arm access is limited, though brachial is standard for older children. Temporal isn't a BP site. Radial is for pulse. Choice A fits some pediatric contexts (e.g., neonates), per nursing texts, despite brachial's commonality.
Question 5 of 5
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 is normal with regular rhythm. Too fast or slow misaligns with norms. Toddler rates are lower (80-130). Choice A is correct, per pediatric vital sign standards.