ATI RN
Assessing Vital Signs ATI Questions
Question 1 of 5
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8°F (36°C), whereas at 4:00 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?
Correct Answer: D
Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.
Question 2 of 5
Vital signs are based on....
Correct Answer: C
Rationale: Vital signs reflect homeostasis , the body's ability to maintain internal stability (e.g., temperature, heart rate). Food processing affects digestion, not vital signs directly. Weight and height inform growth or BMI, not homeostasis monitoring. ‘None of the above' dismisses the correct link. Choice C is correct, as vital signs are physiological markers of homeostatic balance, a principle nurses use to assess health and guide care, per basic pathophysiology.
Question 3 of 5
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
Correct Answer: C
Rationale: Baseline vital signs provide a reference to assess current RR 26 and SpO2 92% against prior recovery, guiding interventions. Activity and meds inform care but not priority. Dyspnea perception is subjective, less critical than objective trends. Choice C is correct, per nursing process emphasizing baseline data for planning effective respiratory care.
Question 4 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 5 of 5
A nurse is assessing a client's pulse rate and finds it to be irregularly irregular with no discernible pattern. What action should the nurse take?
Correct Answer: C
Rationale: Irregularly irregular pulse suggests atrial fibrillation, requiring cardiac monitoring for confirmation. It's not normal . Waiting delays intervention. Breathing doesn't fix arrhythmias. Choice C is correct, per the explanation, aligning with nursing response to potential cardiac irregularities.