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A nurse is planning care for a client who is experiencing tachycardia.
Which of the following interventions should the nurse plan to
include?
1. Instruct the client to increase exercise.
2. Instruct the client to consume no more than four caffeinated
beverages per day.
3. Encourage the client to practice relaxation techniques each day.
4. Encourage the client to engage in pattern-paced breathing by
panting. -
correct answer ✅Encourage the client to practice relaxation
techniques each day.
exp: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, because these can
decrease heart rate and blood pressure.
A nurse is teaching a group of assistive personnel (AP) about
techniques used to obtain BP. For which of the following clients
should the nurse to instruct the AP to obtain an electronic BP
measurement?
1. a pt who has a BP lower than the expected reference range
2. a school-age child
,RN Vital Signs Assessment (ATI) Exam
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3. a pt recovering from extensive abdominal surgery
4. a pt who has stabilised BP measurements -
correct answer ✅A client who has stabilized BP measurements.
exp: Blood pressure can be obtained electronically using a machine
that has a blood pressure cuff attached. The machine automatically
inflates the bladder of the cuff and displays the blood pressure on a
screen. This method is reserved for clients in stable condition with
BP measurements within the expected reference range. Manual BP
measurements are more accurate than those obtained via an
electronic device, so if an abnormal reading is obtained
electronically, a manual reading should be obtained.
A nurse is observing an assistive personnel (AP) obtain vital signs
from an adult client. Which of the following actions by the AP
requires follow up by the nurse?
1. The AP pulls the pinna up and back when obtaining a tympanic
temperature.
2. The AP informs the client when they are counting the
respirations.
3. The AP gently presses down with the pads of two to three fingers
over the radial pulse site.
,RN Vital Signs Assessment (ATI) Exam
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4. The AP selects a blood pressure cuff width that is 40% the
circumference of the client's arm. -
correct answer ✅The AP informs the client when they are
counting the respirations.
exp: According to evidence-based practice, the 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
inaccurate results. When obtaining vital signs, the AP should count
a client's respirations when they are relaxed and at rest.
A charge nurse in a clinic is preparing an in-service about blood
pressure measurements for a group of staff members. Which of the
following information should the nurse include?
1. A client is diagnosed with an elevated blood pressure when the
measurement is greater than 130/80 mm Hg.
2. A client is experiencing a hypertensive crisis when their blood
pressure is greater than 150/90 mm Hg.
3. A client who has a blood pressure of 128/86 mm Hg has stage I
hypertension.
4. A client who has a blood pressure of 162/102 mm Hg has stage II
hypertension. -
, RN Vital Signs Assessment (ATI) Exam
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correct answer ✅A client who has a blood pressure of 162/102
mm Hg has stage II hypertension.
exp: The charge nurse should include that a blood pressure of
162/102 mm Hg meets the diagnostic criteria for stage II
hypertension. With Stage II hypertension, the systolic BP must be
greater than 140 mm Hg and the diastolic BP must be greater than
90 mm Hg.
A charge nurse is reviewing documentation of vital signs by a newly
licensed nurse. Which of the following pieces of documentation is
correct?
1. Pulse 52/min
2. Respiratory rate 24
3. SaO2 97% right index finger, room air
4. Blood pressure 132/86 mm Hg -
correct answer ✅SaO2 97%, Right Index Finger, Room Air
exp: The charge nurse should identify that this documentation is
thorough and complete and does not require any additional
information. The information provided includes the measurement,
the site used, and that the client is not on oxygen.