ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
Which of the following percussion notes would you obtain over the gastric bubble?
Correct Answer: B
Rationale: The correct answer is B: Tympany. When percussing over the gastric bubble, you would expect to hear a tympanic sound due to the presence of gas in the stomach. Tympany is characterized by a drum-like, hollow sound. Resonance (A) is a normal lung sound, hyperresonance (C) is indicative of hyperinflation of the lungs, and flatness (D) is typically heard over solid organs or areas of consolidation in the lungs. Therefore, the presence of a gastric bubble would produce a tympanic note on percussion.
Question 2 of 5
A woman is discussing the problems she is having with her 2-year-old son. She says, 'He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens.' The nurse's best verbal response would be:
Correct Answer: B
Rationale: The correct answer is B: "Fits? Tell me what you mean by this." This response shows active listening and seeks clarification, allowing the nurse to gather more information to better understand the situation and provide appropriate support. It demonstrates empathy and encourages the woman to express her concerns further. Choices A and C are less effective because they do not address the specific issue of the fits the child is having. Choice D is incorrect as it dismisses the woman's emotions and fails to address the underlying problem. Overall, choice B is the best response as it promotes effective communication and understanding between the nurse and the woman.
Question 3 of 5
Before auscultating the abdomen for bowel sounds, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because checking the room temperature and ensuring patient comfort is crucial before auscultating the abdomen to prevent any environmental factors from affecting the patient's comfort or bowel sounds. A, warming the stethoscope, is unnecessary and could potentially be uncomfortable for the patient. B, leaving the gown on, may interfere with the ability to properly listen to bowel sounds. C, ensuring the bell side of the stethoscope is on, is important but not the primary consideration before auscultating the abdomen.
Question 4 of 5
During auscultation, the nurse hears an unfamiliar sound. The best action is to:
Correct Answer: B
Rationale: The correct answer is B because asking another nurse to double-check the finding is crucial for validation and ensuring accuracy in assessment. This step helps in confirming the unfamiliar sound and ruling out any potential errors or misinterpretations. It promotes patient safety and effective communication among healthcare providers. Ignoring the sound (Choice A) can lead to overlooking a significant finding that may impact the patient's condition. Documenting and continuing the assessment (Choice C) without validation may result in incomplete information and potential misdiagnosis. Repositioning the patient and listening again (Choice D) may not address the need for confirmation from another healthcare provider.
Question 5 of 5
Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
Correct Answer: A
Rationale: The correct technique is to count the radial pulse for 1 minute if the rhythm is irregular because irregular rhythms may have fluctuations that can affect accuracy. Counting for a full minute provides a more comprehensive assessment of the pulse rate. Choice B is incorrect because multiplying the count by 4 after 15 seconds may not accurately reflect the pulse rate if the rhythm is irregular. Choice C is incorrect because counting for 2 full minutes is unnecessary and can be time-consuming without providing additional benefits in most cases. Choice D is incorrect as multiplying by 6 after 10 seconds is not suitable for irregular rhythms or for patients with cardiac abnormalities.