ATI RN
Assess Vital Signs Questions
Question 1 of 5
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway using which method?
Correct Answer: C
Rationale: The correct answer is C: Jaw thrust maneuver. This method is used to open the airway in a suspected cervical spine injury. Step 1: Place hands on either side of the patient's face, positioning the thumbs under the jaw. Step 2: Use the thumbs to gently lift the jaw forward, keeping the head in a neutral position. This technique helps maintain alignment of the cervical spine. The other choices are incorrect because A: Flexed position may worsen spinal injury, B: Head tilt-chin lift can cause further trauma in cervical spine injury, and D: Modified head tilt-chin lift is not recommended for suspected spinal injuries.
Question 2 of 5
During a cardiovascular assessment, the nurse auscultates a murmur. How should the nurse describe this finding?
Correct Answer: D
Rationale: The correct answer is D because a murmur is described as a whooshing or swishing sound heard over the heart due to turbulent blood flow. This sound is typically heard during systole or diastole, which aligns with the timing of heart sounds. A: A palpable vibration is more characteristic of a thrill, not a murmur. B: An extra heart sound refers to S3 or S4, not a murmur. C: A high-pitched sound during inspiration is more indicative of wheezing in the lungs, not a murmur.
Question 3 of 5
The nurse is palpating lymph nodes during an assessment. Which characteristic of lymph nodes is concerning?
Correct Answer: D
Rationale: The correct answer is D: Hard and fixed. This characteristic is concerning as it may indicate malignancy or infection. Normal lymph nodes should be soft, mobile, and non-tender. Hard and fixed lymph nodes can be a sign of abnormal growth or metastasis. It is important to monitor such nodes closely and further investigate any concerning findings to rule out serious conditions. Choices A, B, and C describe normal characteristics of lymph nodes and are not typically concerning during assessment.
Question 4 of 5
The nurse is auscultating the lungs and hears a high-pitched, musical sound on expiration. What does this sound indicate?
Correct Answer: A
Rationale: The correct answer is A: Wheezing. Wheezing is a high-pitched, musical sound on expiration caused by narrowing of airways. This indicates obstruction in the lower respiratory tract, commonly seen in conditions like asthma or COPD. Crackles (B) are discontinuous, crackling sounds heard on inspiration and indicate fluid in the alveoli. Pleural friction rub (C) is a grating, rubbing sound heard during inspiration and expiration, suggesting inflammation of the pleura. Stridor (D) is a high-pitched, harsh sound heard on inspiration, indicating upper airway obstruction.
Question 5 of 5
Which finding during an abdominal assessment suggests the presence of ascites?
Correct Answer: B
Rationale: The correct answer is B: Shifting dullness on percussion. Ascites is the accumulation of fluid in the peritoneal cavity. When the patient is in a supine position, the fluid settles by gravity and causes dullness upon percussion in the dependent areas. Shifting dullness occurs when the patient is turned to the side, causing the fluid to shift and the dullness to move. This finding is specific to ascites. A: Hyperresonance on percussion is associated with bowel gas and is typically heard in cases of bowel obstruction. C: Borborygmi on auscultation refers to hyperactive bowel sounds and is not specific to ascites. D: Rebound tenderness on palpation indicates peritoneal irritation, often seen in cases of peritonitis, not ascites. In summary, shifting dullness on percussion is the key finding in assessing ascites due to the movement of fluid in the peritoneal cavity.