ATI RN
Rn Vital Signs Assessment ATI Questions
Question 1 of 5
Which of the following is most likely benign on breast examination?
Correct Answer: B
Rationale: The correct answer is B: One breast larger than the other. This is most likely benign because breast asymmetry is common and often not a sign of serious health issues. Other choices are incorrect: A - dimpling resembling an orange peel is concerning for breast cancer, C - inverted nipple can be a sign of underlying breast pathology, D - dimpling in a breast when leaning forward could indicate an underlying mass or tumor.
Question 2 of 5
The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
Correct Answer: D
Rationale: The correct answer is D. This response indicates the patient is fully oriented to person, place, and time. The patient knows their name, location (hospital in Spokane), and the general time frame (February of a new year—2010). Knowing the specific month and year demonstrates a good level of orientation. Choice A is incorrect because the patient is unsure of their location and gives a vague answer about the year. Choice B is incorrect as the patient admits to being confused about the date. Choice C is incorrect because the patient does not know the date, which is an important aspect of orientation.
Question 3 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 4 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 5 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.