ATI ENGAGE FUNDAMENTALS VITAL SIGNS
COMPREHENSIVE TEST 2026 FULL QUESTIONS
AND ANSWERS GRADED A+
◉ A nurse is contributing to the plan of care for a client who is
experiencing tachycardia. Which of the following interventions
should the nurse plan to recommend?
A. Instruct the client to increase exercise.
B. Instruct the client to consume no more than four caffeinated
beverages per day.
C. Encourage the client to practice relaxation techniques each day.
D. Encourage the client to engage in pattern paced breathing by
panting. Answer: C. Encourage the client to practice relaxation
techniques each day.
Tachycardia can be caused by stress or anxiety. The nurse should
encourage the client to participate in relaxation techniques such as
guided imagery, meditation, or yoga as these can decrease heart rate
and blood pressure.
◉ A nurse is planning care for a group of clients. For which of the
following clients should the nurse direct an assistive personnel (AP)
to obtain a rectal temperature?
A. A toddler who has diarrhea
,B. A client who is 1-day postoperative following a
hemorrhoidectomy and receiving pain medications via PCA pump
C. An infant who is receiving intravenous fluids
D. A client who is diaphoretic and frequently chewing ice to relieve
dry mouth. Answer: D. A client who is diaphoretic and frequently
chewing ice to relieve dry mouth.
Oral temperatures should not be obtained in clients who have
consumed foods or liquids or smoked tobacco products within the
previous 30 min. The client's diaphoresis will make it difficult to
obtain an accurate temperature via the tympanic membrane or
temporal artery. Therefore, the nurse should direct the AP to obtain
this client's temperature rectally.
◉ A nurse is obtaining vital signs for a group of clients. Which of the
following findings requires intervention?
A. A 17-year-old who has a respiratory rate of 16/min
B. A young adult who has a pulse rate of 98/min
C. An 11-year-old child who has a respiratory rate of 34/min
D. An older adult who has a pulse rate of 62/min. Answer: C. An 11-
year-old child who has a respiratory rate of 34/min
The nurse should identify that a respiratory rate of 34/min is above
the expected reference range of 18 to 30/min for a school-age child.
This finding requires intervention by the nurse.
,◉ A nurse is caring for a group of clients. Which of the following
clients is experiencing an alteration in their respiratory rate that
requires intervention?
A. An adolescent who has a respiratory rate of 20/min
B. An older adult who has a respiratory rate of 16/min
C. An infant who has a respiratory rate of 52/min
D. A school-age child who has a respiratory rate of 14/min. Answer:
D. A school-age child who has a respiratory rate of 14/min
The nurse should identify that a respiratory rate of 14/min is below
the expected reference range of 18 to 30/min for a school-age child.
The child is exhibiting bradypnea, which requires further data
collection by the nurse.
◉ A nurse is collecting data from a 3-month-old infant during a well-
child visit. Which of the following actions should the nurse take
when checking the infant's apical pulse?
A. Count the number of beats heard in 15 seconds and multiply by 4.
B. Notify the provider if the apical pulse rate is greater than
110/min.
C. Place the stethoscope over the 4th intercostal space to the left of
the sternum.
, D. Palpate the infant's sternum for the presence of a murmur..
Answer: C. Place the stethoscope over the 4th intercostal space to
the left of the sternum.
The nurse should auscultate the apical 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 of age.
◉ A nurse obtains a client's electronic blood pressure reading of
188/96 mm Hg. Which of the following actions should the nurse
take next?
A. Obtain a manual blood pressure reading from the client.
B. Notify the charge nurse of the client's blood pressure reading.
C. Reinforce client education on measures to decrease blood
pressure.
D. Reinforce client teaching regarding medications to control blood
pressure.. Answer: A. Obtain a manual blood pressure reading from
the client.
Evidence-based practice dictates that if a client's blood pressure is
not within the expected reference range when it is taken with an
electronic blood pressure machine, then the nurse should recheck
the blood pressure by obtaining a manual blood pressure reading to
ensure accuracy.
COMPREHENSIVE TEST 2026 FULL QUESTIONS
AND ANSWERS GRADED A+
◉ A nurse is contributing to the plan of care for a client who is
experiencing tachycardia. Which of the following interventions
should the nurse plan to recommend?
A. Instruct the client to increase exercise.
B. Instruct the client to consume no more than four caffeinated
beverages per day.
C. Encourage the client to practice relaxation techniques each day.
D. Encourage the client to engage in pattern paced breathing by
panting. Answer: C. Encourage the client to practice relaxation
techniques each day.
Tachycardia can be caused by stress or anxiety. The nurse should
encourage the client to participate in relaxation techniques such as
guided imagery, meditation, or yoga as these can decrease heart rate
and blood pressure.
◉ A nurse is planning care for a group of clients. For which of the
following clients should the nurse direct an assistive personnel (AP)
to obtain a rectal temperature?
A. A toddler who has diarrhea
,B. A client who is 1-day postoperative following a
hemorrhoidectomy and receiving pain medications via PCA pump
C. An infant who is receiving intravenous fluids
D. A client who is diaphoretic and frequently chewing ice to relieve
dry mouth. Answer: D. A client who is diaphoretic and frequently
chewing ice to relieve dry mouth.
Oral temperatures should not be obtained in clients who have
consumed foods or liquids or smoked tobacco products within the
previous 30 min. The client's diaphoresis will make it difficult to
obtain an accurate temperature via the tympanic membrane or
temporal artery. Therefore, the nurse should direct the AP to obtain
this client's temperature rectally.
◉ A nurse is obtaining vital signs for a group of clients. Which of the
following findings requires intervention?
A. A 17-year-old who has a respiratory rate of 16/min
B. A young adult who has a pulse rate of 98/min
C. An 11-year-old child who has a respiratory rate of 34/min
D. An older adult who has a pulse rate of 62/min. Answer: C. An 11-
year-old child who has a respiratory rate of 34/min
The nurse should identify that a respiratory rate of 34/min is above
the expected reference range of 18 to 30/min for a school-age child.
This finding requires intervention by the nurse.
,◉ A nurse is caring for a group of clients. Which of the following
clients is experiencing an alteration in their respiratory rate that
requires intervention?
A. An adolescent who has a respiratory rate of 20/min
B. An older adult who has a respiratory rate of 16/min
C. An infant who has a respiratory rate of 52/min
D. A school-age child who has a respiratory rate of 14/min. Answer:
D. A school-age child who has a respiratory rate of 14/min
The nurse should identify that a respiratory rate of 14/min is below
the expected reference range of 18 to 30/min for a school-age child.
The child is exhibiting bradypnea, which requires further data
collection by the nurse.
◉ A nurse is collecting data from a 3-month-old infant during a well-
child visit. Which of the following actions should the nurse take
when checking the infant's apical pulse?
A. Count the number of beats heard in 15 seconds and multiply by 4.
B. Notify the provider if the apical pulse rate is greater than
110/min.
C. Place the stethoscope over the 4th intercostal space to the left of
the sternum.
, D. Palpate the infant's sternum for the presence of a murmur..
Answer: C. Place the stethoscope over the 4th intercostal space to
the left of the sternum.
The nurse should auscultate the apical 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 of age.
◉ A nurse obtains a client's electronic blood pressure reading of
188/96 mm Hg. Which of the following actions should the nurse
take next?
A. Obtain a manual blood pressure reading from the client.
B. Notify the charge nurse of the client's blood pressure reading.
C. Reinforce client education on measures to decrease blood
pressure.
D. Reinforce client teaching regarding medications to control blood
pressure.. Answer: A. Obtain a manual blood pressure reading from
the client.
Evidence-based practice dictates that if a client's blood pressure is
not within the expected reference range when it is taken with an
electronic blood pressure machine, then the nurse should recheck
the blood pressure by obtaining a manual blood pressure reading to
ensure accuracy.
