ATI RN
PN Vital Signs Assessment Questions
Question 1 of 5
The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated?
Correct Answer: C
Rationale: Rectal temperature measurement is contraindicated in specific cases due to risks. For a newborn with hypothermia , its avoided due to fragile rectal tissue and potential perforation risk. A child with pneumonia has no specific rectal contraindication unless diarrhea is present, which isnt mentioned. An older adult post-myocardial infarction is at risk because thermometer insertion can stimulate the vagus nerve, slowing the heart rate, which is dangerous post-MI. A teenager with leukemia may have neutropenia, making rectal measurement risky due to infection potential from low white blood cell counts. Choice C is highlighted as correct in the context, supported by the vagus nerve risk. Other contraindications like rectal surgery or low platelets also apply but align with Cs cardiac focus here. This reflects nursing judgment in prioritizing patient safety based on physiological risks.
Question 2 of 5
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove , ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.
Question 3 of 5
A Normal body temperature can range from...
Correct Answer: C
Rationale: Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C) orally , adjusting slightly by route (e.g., rectal +1°F, axillary -1°F). 95°F to 98°F includes hypothermia. 98°F to 105°F spans fever. 95°F to 100°F is too broad. Choice C is correct, reflecting standard ranges in nursing texts (e.g., Potter & Perry), critical for identifying normothermia versus deviations like fever or hypothermia.
Question 4 of 5
A heart rate measurement, or pulse, can be taken at which pulse point?
Correct Answer: D
Rationale: Pulse can be palpated at radial , brachial , dorsalis pedis , and other sites , depending on accessibility and need. All are valid, with radial most common, brachial for infants, and dorsalis pedis for circulation checks. Choice D is correct, per nursing assessment flexibility, allowing pulse detection across peripheral sites to monitor cardiac function.
Question 5 of 5
The nurse is caring for a patient who has an elevated temperature. The nurse understands that
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.