RN Vital Signs Assessment (ATI) latest 2022

RN Vital Signs Assessment (ATI) latest 2022A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include? Encourage the client to practice relaxation techniques each day. 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? A client who has stabilized BP measurements. 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? The AP informs the client when they are counting the respirations. 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? A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? SaO2 97%, Right Index Finger, Room Air A nurse is assessing a 3-month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? Place the stethoscope over the 4th intercostal space to the left of the sternum. 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 school-age child who has a respiratory rate of 14/min. 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 client who is diaphoretic an frequently chewing ice to relieve dry mouth. A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? A young adult who has a radial pulse rate of 56/min A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? Body temperature is typically lower in older adults. A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? A 11-year old child who has a respiratory rate of 34/min. A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? A young adult who has an apical pulse rate of 104/min. A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? Recording vital signs provides critical information regarding a client's condition. A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse. Apex of the heart. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? Instruct the client to bear down like they are having a bowel movement. A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include? Fever can increase a client's respiratory rate. A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? Increase in blood pressure A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.) - Provide the client with low-sodium meals and snacks - Encourage the client to participate in physical activity each day. - Instruct the client in the use of relaxation techniques. - Inform the client of the importance of abstaining from using products that contain nicotine. A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene? Toddler who has a respiratory rate of 44/min. A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? Oxygen saturation reflects the amount of oxygen being delivered to body tissues. A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include? "Count the respiratory rate for 1 minute for clients who have a respiratory infection." A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. 1. Select the site for obtaining the measurement. 2. Apply the sensor probe on the chosen site. 3. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. 4. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter. A nurse is reviewing the vital signs for four clients. The nurse should identify that which of the following clients has a vital sign outside the expected reference range? A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg. A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature? Oral temperature is easily accessible despite a client's position. A nurse is assessing a client who has orthostatic hypotension. Encourage the client to change positions slowly. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? "A decrease of 20 millimeters of mercury ion the systolic pressure with a position change indicates orthostatic hypotension." A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? BP 124/82 mm Hg, lying in bed A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include? A temporal probe thermometer uses infrared scanning to determine a client's temperature. A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include? Blood pressure is measured an documented in millimeters of mercury. A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse? Dyspnea. A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include? Use the thigh to obtain blood pressure when a client has severe edema in their arms.