ATI Fundamentals | Week 4 NGN Study Guide (Assessment & Vital
Signs) 2026/2027 |Rationales
1. A nurse is measuring a client’s blood pressure and uses a cuff that is too
narrow for the size of the client’s arm. Which of the following results should the
nurse expect?
A. A falsely high reading
B. A falsely low reading
C. A reading that is accurate for the systolic only
D. An inability to hear the Korotkoff sounds
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow will result in a falsely
high blood pressure reading because the cuff must be inflated more to occlude the artery.
2. A nurse is preparing to assess a client’s vital signs. Which of the following is
considered the normal range for an adult’s respiratory rate?
A. 8 to 12 breaths per minute
B. 12 to 20 breaths per minute
C. 20 to 30 breaths per minute
D. 15 to 25 breaths per minute
Answer: B
Rationale: The standard normal respiratory rate for a healthy adult at rest is 12 to 20
breaths per minute.
,3. Which of the following techniques should the nurse perform first when
conducting a comprehensive physical assessment?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Answer: B
Rationale: The standard sequence for physical assessment is inspection, palpation,
percussion, and auscultation (except for the abdominal assessment).
4. A nurse is calculating a client’s pulse deficit. Which of the following methods
should the nurse use?
A. Calculate the difference between the carotid and radial pulses.
B. Measure the radial pulse for 30 seconds and multiply by 2.
C. Subtract the diastolic pressure from the systolic pressure.
D. Calculate the difference between the apical pulse and the radial pulse.
Answer: D
Rationale: A pulse deficit is the difference between the apical pulse rate and the radial
pulse rate when taken simultaneously; it indicates that heart contractions are not reaching
the peripheral pulse.
5. When assessing a client’s rectal temperature, how far should the nurse insert
the lubricated probe into the adult’s rectum?
A. 2 to 3 inches (5 to 7.5 cm)
B. 0.5 inches (1.2 cm)
C. 1 to 1.5 inches (2.5 to 3.5 cm)
D. As far as the probe allows
Answer: C
, Rationale: For an adult, the rectal probe should be inserted approximately 1 to 1.5 inches
toward the umbilicus. Inserting it further can cause injury to the rectal mucosa.
6. During the measurement of blood pressure, the nurse identifies the first clear
tapping sound. Which of the following does this sound represent?
A. The systolic pressure
B. The diastolic pressure
C. The pulse pressure
D. The mean arterial pressure
Answer: A
Rationale: The first Korotkoff sound (Phase 1) is a sharp, rhythmic tapping that
corresponds to the systolic blood pressure.
7. Which of the following factors is known to increase a client’s body
temperature?
A. Early morning hours
B. Ovulation
C. Starvation
D. Hypothyroidism
Answer: B
Rationale: Progesterone release during ovulation increases body temperature. Early
morning is typically when temperature is at its lowest (circadian rhythm).
8. A nurse finds that a client has a heart rate of 110 beats per minute. How
should the nurse document this finding?
A. Bradycardia
B. Dysrhythmia
C. Tachycardia
D. Pulse deficit
Answer: C
Signs) 2026/2027 |Rationales
1. A nurse is measuring a client’s blood pressure and uses a cuff that is too
narrow for the size of the client’s arm. Which of the following results should the
nurse expect?
A. A falsely high reading
B. A falsely low reading
C. A reading that is accurate for the systolic only
D. An inability to hear the Korotkoff sounds
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow will result in a falsely
high blood pressure reading because the cuff must be inflated more to occlude the artery.
2. A nurse is preparing to assess a client’s vital signs. Which of the following is
considered the normal range for an adult’s respiratory rate?
A. 8 to 12 breaths per minute
B. 12 to 20 breaths per minute
C. 20 to 30 breaths per minute
D. 15 to 25 breaths per minute
Answer: B
Rationale: The standard normal respiratory rate for a healthy adult at rest is 12 to 20
breaths per minute.
,3. Which of the following techniques should the nurse perform first when
conducting a comprehensive physical assessment?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Answer: B
Rationale: The standard sequence for physical assessment is inspection, palpation,
percussion, and auscultation (except for the abdominal assessment).
4. A nurse is calculating a client’s pulse deficit. Which of the following methods
should the nurse use?
A. Calculate the difference between the carotid and radial pulses.
B. Measure the radial pulse for 30 seconds and multiply by 2.
C. Subtract the diastolic pressure from the systolic pressure.
D. Calculate the difference between the apical pulse and the radial pulse.
Answer: D
Rationale: A pulse deficit is the difference between the apical pulse rate and the radial
pulse rate when taken simultaneously; it indicates that heart contractions are not reaching
the peripheral pulse.
5. When assessing a client’s rectal temperature, how far should the nurse insert
the lubricated probe into the adult’s rectum?
A. 2 to 3 inches (5 to 7.5 cm)
B. 0.5 inches (1.2 cm)
C. 1 to 1.5 inches (2.5 to 3.5 cm)
D. As far as the probe allows
Answer: C
, Rationale: For an adult, the rectal probe should be inserted approximately 1 to 1.5 inches
toward the umbilicus. Inserting it further can cause injury to the rectal mucosa.
6. During the measurement of blood pressure, the nurse identifies the first clear
tapping sound. Which of the following does this sound represent?
A. The systolic pressure
B. The diastolic pressure
C. The pulse pressure
D. The mean arterial pressure
Answer: A
Rationale: The first Korotkoff sound (Phase 1) is a sharp, rhythmic tapping that
corresponds to the systolic blood pressure.
7. Which of the following factors is known to increase a client’s body
temperature?
A. Early morning hours
B. Ovulation
C. Starvation
D. Hypothyroidism
Answer: B
Rationale: Progesterone release during ovulation increases body temperature. Early
morning is typically when temperature is at its lowest (circadian rhythm).
8. A nurse finds that a client has a heart rate of 110 beats per minute. How
should the nurse document this finding?
A. Bradycardia
B. Dysrhythmia
C. Tachycardia
D. Pulse deficit
Answer: C
