ATI RN
Vital Signs Assessment Chapter 7 Questions
Question 1 of 9
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
Correct Answer: C
Rationale: The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
Question 2 of 9
A home healthcare nurse notices that his assigned patient uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?
Correct Answer: A
Rationale: Flushing mercury is incorrect and hazardous, per the answer key, risking contamination. Not vacuuming , ventilating , and discarding clothing are safe steps. Nurses educate on mercury's toxicity to prevent environmental harm.
Question 3 of 9
The nurse is assessing a patient for signs of anemia. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: Pale conjunctivae are a common sign of anemia due to decreased red blood cell count.
Question 4 of 9
The tissue that connects the tongue to the floor of the mouth is the:
Correct Answer: D
Rationale: The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.
Question 5 of 9
A nurse is conducting a health assessment for an African American patient. What should the nurse consider in terms of cultural sensitivity?
Correct Answer: C
Rationale: Cultural risk factors and racial variations , per the answer key, guide sensitive assessments (e.g., hypertension in African Americans). Uniformity , race questions , or emotional needs miss this focus. Nurses, per Taylor, adapt care culturally.
Question 6 of 9
A nurse is assessing a client's pulse rate and observes an irregular rhythm with skipped beats. What action should the nurse take?
Correct Answer: C
Rationale: Irregular rhythm with skipped beats suggests a potential arrhythmia, requiring provider notification for evaluation. It's not normal . Waiting an hour delays care. Deep breathing doesn't address cardiac issues. Choice C is correct, per the explanation, reflecting nursing's duty to escalate abnormal findings promptly for patient safety.
Question 7 of 9
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
Correct Answer: A
Rationale: Newborn respiratory rate is 30-60 breaths/min; rapid breathing within this is normal if pink, warm, dry. Lower ranges (B, C, D) apply to older ages. Choice A is correct, per neonatal norms, guiding care planning.
Question 8 of 9
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
Correct Answer: A
Rationale: Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
Question 9 of 9
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: A stronger percussion stroke is needed for obese or muscular individuals.