RN Vital Signs Assessment (ATI) Test Questions and
Answers Rated A
A nurse is planning care for a client who is
experiencing tachycardia. Which of the following
interventions should the nurse plan to include? A nurse is observing an assistive personnel (AP)
1. Instruct the client to increase exercise. obtain vital signs from an adult client. Which of
2. Instruct the client to consume no more than the following actions by the AP requires follow up
four caffeinated beverages per day. by the nurse?
3. Encourage the client to practice relaxation 1. The AP pulls the pinna up and back when
techniques each day. obtaining a tympanic temperature.
4. Encourage the client to engage in pattern- 2. The AP informs the client when they are
paced breathing by panting. - - Encourage counting the respirations.
the client to practice relaxation techniques each 3. The AP gently presses down with the pads of
day. two to three fingers over the radial pulse site.
exp:Tachycardia can be caused by stress or 4. The AP selects a blood pressure cuff width
anxiety. The nurse should encourage the client that is 40% the circumference of the client's arm.
to participate in relaxation techniques such as - - The AP informs the client when they are
guided imagery, meditation, or yoga, because counting the respirations.
these can decrease heart rate and blood exp: According to evidence-based practice, the
pressure. AP should not inform the client they are going to
count their respirations. This action can lead the
client to alter their breathing, which can cause
A nurse is teaching a group of assistive inaccurate results. When obtaining vital signs, the
personnel (AP) about techniques used to obtain AP should count a client's respirations when they
BP. For which of the following clients should the are relaxed and at rest.
nurse to instruct the AP to obtain an electronic
BP measurement?
1. a pt who has a BP lower than the expected A charge nurse in a clinic is preparing an in-
reference range service about blood pressure measurements for
2. a school-age child a group of staff members. Which of the following
3. a pt recovering from extensive abdominal information should the nurse include?
surgery 1. A client is diagnosed with an elevated blood
4. a pt who has stabilised BP measurements - pressure when the measurement is greater than
- A client who has stabilized BP 130/80 mm Hg.
measurements. 2. A client is experiencing a hypertensive crisis
exp: Blood pressure can be obtained when their blood pressure is greater than 150/90
electronically using a machine that has a blood mm Hg.
pressure cuff attached. The machine 3. A client who has a blood pressure of 128/86
automatically inflates the bladder of the cuff and mm Hg has stage I hypertension.
displays the blood pressure on a screen. This 4. A client who has a blood pressure of 162/102
method is reserved for clients in stable condition mm Hg has stage II hypertension. - -A
with BP measurements within the expected client who has a blood pressure of 162/102 mm
reference range. Manual BP measurements are Hg has stage II hypertension.
more accurate than those obtained via an exp: The charge nurse should include that a
electronic device, so if an abnormal reading is blood pressure of 162/102 mm Hg meets the
obtained electronically, a manual reading should diagnostic criteria for stage II hypertension. With
be obtained. Stage II hypertension, the systolic BP must be
, RN Vital Signs Assessment (ATI) Test Questions and
Answers Rated A
greater than 140 mm Hg and the diastolic BP 2. An older adult who has a respiratory rate of
must be greater than 90 mm Hg. 16/min
3. An infant who has a respiratory rate of 52/min
4. A school-age child who has a respiratory rate
A charge nurse is reviewing documentation of of 14/min - - A school-age child who has a
vital signs by a newly licensed nurse. Which of respiratory rate of 14/min.
the following pieces of documentation is correct? exp: The nurse should identify that a respiratory
1. Pulse 52/min rate of 14/min is below the expected reference
2. Respiratory rate 24 range of 18 to 30/min for a school-age child. The
3. SaO2 97% right index finger, room air child is exhibiting bradypnea, which requires
4. Blood pressure 132/86 mm Hg - - SaO2 further data collection by the nurse.
97%, Right Index Finger, Room Air
exp: The charge nurse should identify that this
documentation is thorough and complete and A nurse is planning care for a group of clients.
does not require any additional information. The For which of the following clients should the
information provided includes the measurement, nurse direct an assistive personnel (AP) to obtain
the site used, and that the client is not on a rectal temperature?
oxygen. 1. A toddler who has diarrhea
2. A client who is 1 day postoperative following a
hemorrhoidectomy and receiving pain
A nurse is assessing a 3-month old infant during medications via PCA pump
a well-child visit. Which of the following actions 3. An infant who is receiving intravenous fluids
should the nurse take when assessing the apical 4. A client who is diaphoretic and frequently
pulse? chewing ice to relieve dry mouth - - A client
1. Count the number of beats heard in 15 who is diaphoretic an frequently chewing ice to
seconds and multiply by 4. relieve dry mouth.
2. Notify the provider if the apical pulse rate is exp: Oral temperatures should not be obtained in
greater than 110/min. clients who have consumed food or liquids or
3. Place the stethoscope over the 4th intercostal smoked tobacco products within the previous 30
space to the left of the sternum. min. The client's diaphoresis will make it difficult
4. Auscultate the apical pulse for an S4 heart to obtain an accurate temperature via the
sound. - - Place the stethoscope over the tympanic membrane or temporal artery.
4th intercostal space to the left of the sternum. Therefore, the nurse should direct the AP to
exp: The nurse should auscultate the apical obtain this client's temperature rectally.
pulse over the apex of the heart, which is located
in the 4th intercostal space to the left of the
sternum in infants and children less than 7 years A nurse is reviewing the vital signs for a group of
of age. clients obtained by an assistive personnel. The
nurse should identify that which of the following
clients requires a follow-up assessment due to
A nurse is caring for a group of clients. Which of bradycardia?
the following clients is experiencing an alteration 1. A school-age child who has an apical pulse
in their respiratory rate that requires intervention? rate of 78/min
1. An adolescent who has a respiratory rate of 2. A young adult who has a radial pulse rate of
20/min 56/min
Answers Rated A
A nurse is planning care for a client who is
experiencing tachycardia. Which of the following
interventions should the nurse plan to include? A nurse is observing an assistive personnel (AP)
1. Instruct the client to increase exercise. obtain vital signs from an adult client. Which of
2. Instruct the client to consume no more than the following actions by the AP requires follow up
four caffeinated beverages per day. by the nurse?
3. Encourage the client to practice relaxation 1. The AP pulls the pinna up and back when
techniques each day. obtaining a tympanic temperature.
4. Encourage the client to engage in pattern- 2. The AP informs the client when they are
paced breathing by panting. - - Encourage counting the respirations.
the client to practice relaxation techniques each 3. The AP gently presses down with the pads of
day. two to three fingers over the radial pulse site.
exp:Tachycardia can be caused by stress or 4. The AP selects a blood pressure cuff width
anxiety. The nurse should encourage the client that is 40% the circumference of the client's arm.
to participate in relaxation techniques such as - - The AP informs the client when they are
guided imagery, meditation, or yoga, because counting the respirations.
these can decrease heart rate and blood exp: According to evidence-based practice, the
pressure. AP should not inform the client they are going to
count their respirations. This action can lead the
client to alter their breathing, which can cause
A nurse is teaching a group of assistive inaccurate results. When obtaining vital signs, the
personnel (AP) about techniques used to obtain AP should count a client's respirations when they
BP. For which of the following clients should the are relaxed and at rest.
nurse to instruct the AP to obtain an electronic
BP measurement?
1. a pt who has a BP lower than the expected A charge nurse in a clinic is preparing an in-
reference range service about blood pressure measurements for
2. a school-age child a group of staff members. Which of the following
3. a pt recovering from extensive abdominal information should the nurse include?
surgery 1. A client is diagnosed with an elevated blood
4. a pt who has stabilised BP measurements - pressure when the measurement is greater than
- A client who has stabilized BP 130/80 mm Hg.
measurements. 2. A client is experiencing a hypertensive crisis
exp: Blood pressure can be obtained when their blood pressure is greater than 150/90
electronically using a machine that has a blood mm Hg.
pressure cuff attached. The machine 3. A client who has a blood pressure of 128/86
automatically inflates the bladder of the cuff and mm Hg has stage I hypertension.
displays the blood pressure on a screen. This 4. A client who has a blood pressure of 162/102
method is reserved for clients in stable condition mm Hg has stage II hypertension. - -A
with BP measurements within the expected client who has a blood pressure of 162/102 mm
reference range. Manual BP measurements are Hg has stage II hypertension.
more accurate than those obtained via an exp: The charge nurse should include that a
electronic device, so if an abnormal reading is blood pressure of 162/102 mm Hg meets the
obtained electronically, a manual reading should diagnostic criteria for stage II hypertension. With
be obtained. Stage II hypertension, the systolic BP must be
, RN Vital Signs Assessment (ATI) Test Questions and
Answers Rated A
greater than 140 mm Hg and the diastolic BP 2. An older adult who has a respiratory rate of
must be greater than 90 mm Hg. 16/min
3. An infant who has a respiratory rate of 52/min
4. A school-age child who has a respiratory rate
A charge nurse is reviewing documentation of of 14/min - - A school-age child who has a
vital signs by a newly licensed nurse. Which of respiratory rate of 14/min.
the following pieces of documentation is correct? exp: The nurse should identify that a respiratory
1. Pulse 52/min rate of 14/min is below the expected reference
2. Respiratory rate 24 range of 18 to 30/min for a school-age child. The
3. SaO2 97% right index finger, room air child is exhibiting bradypnea, which requires
4. Blood pressure 132/86 mm Hg - - SaO2 further data collection by the nurse.
97%, Right Index Finger, Room Air
exp: The charge nurse should identify that this
documentation is thorough and complete and A nurse is planning care for a group of clients.
does not require any additional information. The For which of the following clients should the
information provided includes the measurement, nurse direct an assistive personnel (AP) to obtain
the site used, and that the client is not on a rectal temperature?
oxygen. 1. A toddler who has diarrhea
2. A client who is 1 day postoperative following a
hemorrhoidectomy and receiving pain
A nurse is assessing a 3-month old infant during medications via PCA pump
a well-child visit. Which of the following actions 3. An infant who is receiving intravenous fluids
should the nurse take when assessing the apical 4. A client who is diaphoretic and frequently
pulse? chewing ice to relieve dry mouth - - A client
1. Count the number of beats heard in 15 who is diaphoretic an frequently chewing ice to
seconds and multiply by 4. relieve dry mouth.
2. Notify the provider if the apical pulse rate is exp: Oral temperatures should not be obtained in
greater than 110/min. clients who have consumed food or liquids or
3. Place the stethoscope over the 4th intercostal smoked tobacco products within the previous 30
space to the left of the sternum. min. The client's diaphoresis will make it difficult
4. Auscultate the apical pulse for an S4 heart to obtain an accurate temperature via the
sound. - - Place the stethoscope over the tympanic membrane or temporal artery.
4th intercostal space to the left of the sternum. Therefore, the nurse should direct the AP to
exp: The nurse should auscultate the apical obtain this client's temperature rectally.
pulse over the apex of the heart, which is located
in the 4th intercostal space to the left of the
sternum in infants and children less than 7 years A nurse is reviewing the vital signs for a group of
of age. clients obtained by an assistive personnel. The
nurse should identify that which of the following
clients requires a follow-up assessment due to
A nurse is caring for a group of clients. Which of bradycardia?
the following clients is experiencing an alteration 1. A school-age child who has an apical pulse
in their respiratory rate that requires intervention? rate of 78/min
1. An adolescent who has a respiratory rate of 2. A young adult who has a radial pulse rate of
20/min 56/min
