ATI RN
Vital Signs Assessment Questions
Question 1 of 5
The patient with heart failure is restless with a temperature of 102.2°F (39°C). Which action will the nurse take?
Correct Answer: A
Rationale: Heart failure with fever (102.2°F) and restlessness suggests increased oxygen demand. Applying oxygen addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing is irrelevant without respiratory symptoms. Restricting fluids may worsen dehydration in fever. Increasing metabolic rate exacerbates stress. Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.
Question 2 of 5
Variations in body temperature can be caused by...
Correct Answer: D
Rationale: Body temperature varies with exercise increasing it via metabolism, gender with slight differences (e.g., women post-ovulation), and cold fluids potentially lowering oral readings. All are factors. Choice D is correct, as nursing recognizes these influencesexercise raises heat production, gender affects baseline, and fluids alter local readingsrequiring context in temperature assessment to ensure accurate interpretation and care planning.
Question 3 of 5
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?
Correct Answer: C
Rationale: Bradycardia (pulse 44) with dizziness/fatigue requires apical pulse assessment to confirm rate and check for deficit, indicating cardiac output issues. Repeating radial delays RN evaluation. Stat ECG is secondary. Meds are premature. Choice C is correct, per nursing priority to verify and assess symptomatic bradycardia directly.
Question 4 of 5
While the nurse is assessing the patient's respirations, it is important for the patient to
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
A nurse is assessing a client's respiratory rate using a pulse oximeter. Where should the nurse place the pulse oximeter sensor to accurately measure the respiratory rate?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.