ATI RN
Vital Signs Assessment Nursing Questions
Question 1 of 5
The nurse is performing a respiratory assessment and notes that the patient has a prolonged inspiratory phase. What condition is most likely associated with this finding?
Correct Answer: D
Rationale: The correct answer is D: Upper airway obstruction. A prolonged inspiratory phase suggests difficulty in inhaling, which is common in upper airway obstructions like a foreign body or swollen tissues. Asthma (A) typically presents with wheezing and expiratory phase prolongation. Pneumonia (B) is characterized by crackles and decreased breath sounds. Pulmonary edema (C) manifests as crackles and shortness of breath. Therefore, based on the prolonged inspiratory phase, the most likely condition is an upper airway obstruction.
Question 2 of 5
Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference?
Correct Answer: A
Rationale: A pulse deficit is the difference between the apical (heart) and radial (peripheral) pulse rates, indicating not all heartbeats reach the periphery, often due to weak contractions or arrhythmias. Here, an 8 beats/min difference fits this definition. Pulse amplitude describes the strength or volume of the pulse, not a rate difference. Ventricular rhythm refers to the hearts rhythm pattern, not a deficit. Heart arrhythmia is a broad term for irregular rhythms but doesnt specifically denote the apical-radial gap. Choice A is correct as it precisely describes the phenomenon observed, reflecting nursing terminology for documenting discrepancies in pulse assessment. This finding may prompt further cardiac evaluation, highlighting the importance of accurate documentation in patient care.
Question 3 of 5
Which peripheral pulse site is generally used in emergency situations?
Correct Answer: A
Rationale: In emergencies, rapid pulse detection is critical. Carotid is easily accessible, strong, and reliable even in low perfusion, making it standard (e.g., CPR). Apical requires a stethoscope, slowing assessment. Radial may be weak in shock. Temporal is less prominent. Choice A is correct, aligning with emergency protocols (e.g., AHA) for quick, effective pulse checks in urgent scenarios.
Question 4 of 5
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?
Correct Answer: B
Rationale: Chronic lung disease (e.g., COPD) with smoking risks CO2 retention; cautious oxygen use prevents suppressing hypoxic drive while addressing shortness of breath. Paper bag is for hyperventilation. High oxygen risks respiratory depression. CO2 worsens hypoxia. Choice B is correct, per respiratory nursing guidelines.
Question 5 of 5
The blood pressure is...
Correct Answer: A
Rationale: Blood pressure is the force of blood against artery walls , measured as systolic and diastolic pressures. Blood volume influences it but isn't the definition. Heartbeats define pulse, not BP. ‘All' is incorrect. Choice A is correct, per cardiovascular nursing principles, distinguishing BP as a pressure metric critical for assessing circulation and organ perfusion.