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Exam (elaborations)

ATI Physical Assessment skill quiz Questions with Detailed Verified Answers

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ATI Physical Assessment skill quiz Questions with Detailed Verified Answers

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ATI Physical Assessment skill quiz Questions with
Detailed Verified Answers



Which action would take priority if a patient's apical pulse has an irregular rhythm?



A. Reassess the pulse for 1 full minute.

B. Assess the patient's peripheral pulses.

C. Wait 5 minutes, and then reassess the apical pulse.

D. Review documentation regarding an irregular rhythm. Ans: ✓ ✓ ✓ A. Reassess the pulse for 1
full minute.

Which statement demonstrates an understanding of the importance of communicating changes in
the patient's apical pulse rate?



A. "The patient's apical pulse is recorded as you asked."

B. "The apical pulse is more difficult to hear when the patient is sitting up."

C. "The apical pulse is usually slower in the morning than it is in the afternoon."

D. "The apical pulse increased from 78 to 110, but the patient had just returned from the
bathroom." Ans: ✓ ✓ ✓ D. "The apical pulse increased from 78 to 110, but the patient had just
returned from the bathroom."

What is the primary purpose of initially assessing an apical pulse?



A. Assessment of the patient's cardiac function

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B. Establishment of a baseline as part of the patient's vital signs

C. Assessment of the patient's risk for cardiovascular disease

D. Determination of oxygen saturation Ans: ✓ ✓ ✓ B. Establishment of a baseline as part of the
patient's vital signs

What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate
technique when measuring the adult patient's apical pulse?



A. Document the patient's pulse rate and rhythm.

B. Place the patient in the right lateral position before measuring the apical pulse.

C. Review the patient's previous apical pulse measurements.

D. Place your stethoscope at the fifth intercostal space over the left midclavicular line. Ans: ✓ ✓ ✓
D. Place your stethoscope at the fifth intercostal space over the left midclavicular line.

The nurse can best determine the effect of crying on a patient's apical pulse by doing what?



A. Measuring the patient's apical pulse before and after crying

B. Assessing the patient's apical pulse 30 minutes after crying

C. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate.

D. Measuring the patient's pulse deficit after crying Ans: ✓ ✓ ✓ C. Comparing the patient's post-
crying apical pulse rate with her baseline or previous rate.

What is the major health problem resulting from a pulse deficit?



A. Bradycardia

B. Activity intolerance

C. Decreased cardiac output

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D. Impaired tissue perfusion Ans: ✓ ✓ ✓ C. Decreased cardiac output

What should the nurse do when a pulse deficit is suspected?



A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.

B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.

C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1
minute.

D. Ask another health care provider to count the radial pulse while the nurse counts the apical
pulse. Ans: ✓ ✓ ✓ D. Ask another health care provider to count the radial pulse while the nurse
counts the apical pulse.

You have the following information:

Oral temperature-36.8°C.

Radial Pulse-112 weak, thready

Apical pulse-117 regular

Respirations-24 regular

Blood Pressure-104/56 right arm

-102/50 left arm



What is the pulse deficit?

A. 2

B. 5

C. 6

D. 48 Ans: ✓ ✓ ✓ B. 5

Which action should the nurse perform after identifying a pulse deficit?
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