ATI RN
EMT Vital Signs Assessment Questions
Question 1 of 5
The nurse keeps in mind the most important step to prevent microorganism transmission in hospitals is:
Correct Answer: C
Rationale: The correct answer is C: Washing hands before and after contact with patients. Hand hygiene is the most crucial step to prevent microorganism transmission in hospitals. It helps reduce the spread of infections from patient to patient and healthcare workers. Washing hands effectively removes bacteria and viruses, preventing their transmission. Wearing protective eyewear (A) is important for eye protection but does not directly prevent microorganism transmission. Wearing gloves (B) is essential for specific patient interactions but does not address all instances of transmission. Cleaning stethoscopes (D) is important for equipment hygiene, but handwashing is more critical for overall infection control.
Question 2 of 5
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
Correct Answer: C
Rationale: Rationale: Choice C is correct because the force of a pulse is a reflection of the heart's stroke volume. The pulse strength is directly proportional to the volume of blood ejected by the heart with each beat. This means that a strong pulse indicates a larger stroke volume, while a weak pulse indicates a smaller stroke volume. Choices A, B, and D are incorrect because pulse strength is not typically recorded on a 0- to 2-point scale, does not directly demonstrate elasticity of the vessel wall, and is not solely a reflection of blood volume in the arteries during diastole.
Question 3 of 5
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
Correct Answer: C
Rationale: The correct answer is C: Systolic blood pressure may be falsely low. An auscultatory gap is a silent interval between the Korotkoff sounds during blood pressure measurement, commonly seen in hypertension. If the nurse does not check for an auscultatory gap, they may miss this silent interval, leading to an underestimation of the systolic blood pressure. Choices A and B are incorrect because missing an auscultatory gap does not affect the ability to hear diastolic blood pressure or result in a falsely low diastolic reading. Choice D is incorrect as missing an auscultatory gap would not lead to a falsely high systolic blood pressure.
Question 4 of 5
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
Correct Answer: C
Rationale: The correct answer is C: Distended veins. When a patient has been confined with his feet down for an extended period, it can lead to venous pooling in the lower extremities, causing the veins to become distended. This occurs due to decreased venous return and increased pressure in the veins. Pallor, coolness, and prolonged capillary filling time would not be expected findings in this situation as they are more indicative of arterial insufficiency or decreased perfusion, which is not the primary concern in this scenario. Distended veins are a common manifestation of venous stasis, making it the most appropriate choice in this context.
Question 5 of 5
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this scenario, the presence of bilateral pitting edema in a patient with a history of hypertension and coronary artery disease suggests fluid overload due to heart failure. The puffy and tight skin without redness or tenderness indicates the edema is non-inflammatory. Equal and strong peripheral pulses suggest good circulation, ruling out venous thrombosis. Absence of signs like redness, warmth, or pain in the legs excludes local inflammation. Blockage of lymphatic drainage typically presents with unilateral edema and is less common in this patient population. Therefore, given the patient's history and physical findings, heart failure is the most likely cause of the bilateral pitting edema.