ATI RN
CNS Vital Signs Assessment Questions
Question 1 of 4
The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should
Correct Answer: B
Rationale: Chronic lung disease (e.g., COPD) risks CO2 retention; cautious oxygen avoids suppressing hypoxic drive. High oxygen is dangerous. Paper bag and CO2 worsen hypoxia. Choice B is correct, per respiratory nursing.
Question 2 of 4
A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?
Correct Answer: B
Rationale: Irregular waveform suggests sensor issues; reapplying on another finger ensures accuracy. It's not normal . Distress or provider action follows if persistent. Choice B is correct, per the explanation, troubleshooting first in nursing practice.
Question 3 of 4
What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?
Correct Answer: C
Rationale: Oral is contraindicated in unconscious patients, per the answer key, due to choking risk with glass thermometers. Rectal , tympanic , and axillary are safer alternatives. Nurses prioritize patient safety, avoiding oral routes in non-responsive states.
Question 4 of 4
A school nurse is preparing to test the auditory function of grade school students. What equipment will be needed for this examination?
Correct Answer: A
Rationale: A tuning fork , per the answer key, tests hearing via vibration (e.g., Rinne, Weber tests). Percussion hammers , speculums , and ophthalmoscopes assess reflexes, nose/ears, or eyes. Nurses, per Taylor, use this for efficient auditory screening in schools.