ATI RN
Vital Signs Assessment for Nurses Questions
Question 1 of 5
You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial insufficiency. You perform the Allen test. This means that you:
Correct Answer: C
Rationale: The correct answer is C: Checked for patency of the ulnar artery. The Allen test is used to assess the collateral circulation of the hand before arterial blood sampling from the radial artery. This involves occluding both the ulnar and radial arteries and then releasing pressure on the ulnar artery while observing the return of color to the hand. If the ulnar artery is patent, the hand should regain color within 5-10 seconds, indicating adequate collateral circulation. This is important to prevent ischemic complications. Choice A (Checked for patency of the radial artery) is incorrect because the Allen test specifically evaluates the ulnar artery's patency, not the radial artery. Choice B (Checked for patency of the brachial artery) is incorrect because the Allen test focuses on the collateral circulation in the hand, not the brachial artery. Choice D (Checked for patency of the femoral artery) is incorrect because the Allen test is not used to assess the femoral artery
Question 2 of 5
The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?
Correct Answer: B
Rationale: The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement. A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results. C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size. D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.
Question 3 of 5
In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.
Question 4 of 5
A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?
Correct Answer: B
Rationale: The correct answer is B: Re-examine the patient and establish new goals. This is the most appropriate next step because if the patient has not shown progress in over three weeks, it indicates a need to reassess the current treatment plan and goals. By re-examining the patient, the therapist can identify any factors hindering progress and adjust the treatment plan accordingly. This proactive approach ensures the patient receives the most effective care. Choice A: Transferring the patient to another therapist does not address the root cause of the lack of progress and may disrupt continuity of care. Choice C: Simply continuing to modify the treatment plan without re-evaluating the patient may not lead to improved outcomes. Choice D: Alerting the referring physician should be done after reassessment and establishing new goals, as the physician may require updated information but is not the immediate next step.
Question 5 of 5
A physical therapist educates a patient on how to use a mechanical lift to transfer a family member from bed to a wheelchair. The therapist explains that the MOST important instruction for the caregiver is to:
Correct Answer: B
Rationale: The correct answer is B: Position the sling appropriately under the patient. This is crucial as an improperly positioned sling can lead to discomfort or injury for the patient during the transfer. By ensuring the sling is correctly placed, the caregiver can provide proper support and enhance the safety of the transfer. Placing the patient's arms outside of the sling (choice A) is important but not as critical as positioning the sling correctly. Locking the lift after positioning the patient in the wheelchair (choice C) is important for safety but not as crucial as ensuring the sling placement. Maintaining good body mechanics during the transfer (choice D) is also important for the caregiver's safety, but the priority should be on positioning the sling properly to ensure the patient's safety and comfort.