ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration?
Correct Answer: C
Rationale: The correct answer is C: Bronchial. Bronchial sounds are louder and higher in pitch compared to vesicular and bronchovesicular sounds. There is a short silence between inspiration and expiration, characteristic of bronchial sounds. Additionally, expiration is longer than inspiration in bronchial sounds. Bronchovesicular sounds have equal inspiration and expiration phases, vesicular sounds are softer and lower in pitch, and tracheal sounds are harsh and heard over the trachea.
Question 2 of 5
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, 'I quit smoking after my wife died 7 years ago.' However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the discrepancy between the patient's statement and the observation made by the nurse. By using confrontation in a non-judgmental manner, the nurse can bring attention to the inconsistency and encourage Mr. K. to clarify his tobacco use accurately. This approach promotes honesty and trust between the nurse and the patient. Choice A is incorrect because it is accusatory and may lead to defensiveness from the patient. Choice B is also incorrect as it does not address the observed behavior and may not effectively resolve the discrepancy. Choice C is invalid as it shifts the focus away from the issue of tobacco use and towards the patient's personal life, which is not the primary concern in this scenario.
Question 3 of 5
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
Correct Answer: B
Rationale: The correct answer is B: Use a Doppler device to check for pulsations. This is the best action because a Doppler device can detect blood flow even when pulses are weak or difficult to palpate. A: Auscultating with a fetoscope is not suitable for assessing pulses. C: Checking for pulsations with a goniometer is used to measure joint angles, not pulses. D: Using a stethoscope to auscultate the pulse may not provide accurate information compared to a Doppler device.
Question 4 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 5 of 5
When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to:
Correct Answer: B
Rationale: The correct answer is B: Consider this finding normal in children and young adults. Rationale: 1. This phenomenon is known as respiratory sinus arrhythmia, which is a normal variation in heart rate seen in children and young adults. 2. It occurs due to the physiological response of the autonomic nervous system to changes in intrathoracic pressure during respiration. 3. In children, the heart rate normally speeds up during inspiration and slows down during expiration. 4. Since this is a normal finding, there is no need to notify the physician or consider it as bradycardia. Summary of other choices: A: Not necessary to immediately notify the physician as this is a normal finding. C: Checking the blood pressure is not indicated as the pulse variation with respiration is a separate phenomenon. D: Documenting bradycardia is incorrect as this is not the case here.