ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The nurse is performing an abdominal assessment and detects a pulsatile mass in the midline of the abdomen. What condition is most likely associated with this finding?
Correct Answer: A
Rationale: The correct answer is A: Abdominal aortic aneurysm. The detection of a pulsatile mass in the midline of the abdomen is highly indicative of an abdominal aortic aneurysm. This is because the aorta runs in the midline of the abdomen, and an aneurysm in this area can present as a pulsatile mass. An abdominal aortic aneurysm is a serious condition that requires immediate medical attention. Choices B, C, and D are incorrect because cholecystitis, pancreatitis, and gastritis do not typically present with a pulsatile mass in the midline of the abdomen.
Question 2 of 5
96.0 to 99.5 degrees Fahrenheit is the normal temperature range of which age group?
Correct Answer: C
Rationale: Neonate, is correct because the normal body temperature range for newborns (birth to 28 days) is approximately 96.0°F to 99.5°F, depending on measurement site (e.g., axillary). Neonates have immature thermoregulation, leading to a slightly wider and lower range than adults. Toddler (1-3 years), typically has a range closer to 97.5°F-100.4°F. Adolescent, aligns with adult norms (97°F-99°F). Middle adult, also falls within 97°F-99°F, narrower than the neonate range. Neonates susceptibility to environmental changes and less efficient hypothalamus function explain this broader range. Clinical practice confirms 96.0°F-99.5°F as typical for neonates, especially in controlled settings like nurseries, making C the accurate answer based on pediatric physiology.
Question 3 of 5
The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated?
Correct Answer: C
Rationale: Rectal temperature measurement is contraindicated in specific cases due to risks. For a newborn with hypothermia , its avoided due to fragile rectal tissue and potential perforation risk. A child with pneumonia has no specific rectal contraindication unless diarrhea is present, which isnt mentioned. An older adult post-myocardial infarction is at risk because thermometer insertion can stimulate the vagus nerve, slowing the heart rate, which is dangerous post-MI. A teenager with leukemia may have neutropenia, making rectal measurement risky due to infection potential from low white blood cell counts. Choice C is highlighted as correct in the context, supported by the vagus nerve risk. Other contraindications like rectal surgery or low platelets also apply but align with Cs cardiac focus here. This reflects nursing judgment in prioritizing patient safety based on physiological risks.
Question 4 of 5
A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent?
Correct Answer: B
Rationale: In pulse documentation, 3+ indicates amplitude (strength) on a 0-4+ scale (0 absent, 1+ weak, 2+ normal, 3+ strong, 4+ bounding). Here, 85 is the rate, regular is rhythm, and equal across sites rules out deficit. Pulse rate is 85, not 3+. Pulse quality fits 3+, reflecting strength. Rhythm is described as regular, not 3+. Deficit isn't indicated. Choice B is correct, aligning with standard nursing terminology for pulse assessment, crucial for evaluating circulation.
Question 5 of 5
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove , ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.