ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
When using Standard Precautions in healthcare, which statement is true?
Correct Answer: C
Rationale: The correct answer is C because Standard Precautions are designed to reduce microorganism transmission from all patients, regardless of their infection status. This includes using personal protective equipment (PPE) like gloves, gowns, masks, and face shields when necessary. These precautions are not limited to high-risk patients or specific body fluids; they apply to all patients and all body fluids. Choice A is incorrect because sweat is not considered a high-risk body fluid for transmission of infections. Choice B is incorrect as Standard Precautions are meant for all patients, not just high-risk ones. Choice D is incorrect because gloves are required based on risk assessment, not necessarily for every patient interaction.
Question 2 of 5
The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. In children, the disappearance of phase V Korotkoff sounds is commonly used to determine diastolic blood pressure. 2. Phase V represents the complete cessation of sound, indicating the return of blood flow to normal. 3. This method is preferred over phase IV sounds due to the potential for overestimating diastolic pressure. 4. Utilizing phase V ensures a more accurate diastolic reading in children. Summary of other choices: A: Blood pressure guidelines for children are based on height, not age. B: Phase I Korotkoff sounds indicate the initial appearance of faint tapping sounds, not phase II. C: Doppler devices are not routinely recommended for blood pressure measurements in children.
Question 3 of 5
A patient comes in for a physical examination and complains of 'freezing to death' while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:
Correct Answer: C
Rationale: The correct answer is C: Peripheral vasoconstriction. When the body is exposed to cold temperatures, peripheral vasoconstriction occurs to conserve heat by reducing blood flow to the skin. This leads to pale and cool skin. Venous pooling (A) refers to blood pooling in the veins due to gravity, not related to cold exposure. Peripheral vasodilation (B) would result in warm, flushed skin, opposite of the presented symptoms. Decreased arterial perfusion (D) would manifest as cold, pale skin but does not explain the specific mechanism of vasoconstriction in response to cold.
Question 4 of 5
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
Correct Answer: C
Rationale: The correct answer is C, severe dehydration. Decreased skin turgor is a clinical sign of dehydration due to fluid loss, causing the skin to lose its elasticity. In contrast, severe obesity (choice A) would not typically result in decreased skin turgor. Childhood growth spurts (choice B) do not directly affect skin turgor. Connective tissue disorders like scleroderma (choice D) may affect skin quality, but decreased skin turgor specifically indicates dehydration. Therefore, choice C is the most likely condition associated with decreased skin turgor.
Question 5 of 5
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because it provides a physiological explanation for the child's frequent ear infections. The eustachian tube in young children is indeed shorter and wider than in adults, making it easier for infections to develop. This is due to the anatomy of the child's ear, not necessarily indicating a more severe underlying issue. Choice A is incorrect as it implies there must be something else wrong, which is not necessarily the case. Choice B is incorrect as checking the immune system may not be the first step in addressing frequent ear infections. Choice C is incorrect as cerumen is not directly related to the development of ear infections in this context.