ATI ENGAGE FUNDAMENTALS: VITAL SIGNS QUESTIONS WITH CORRECT ANSWERS

A nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? A. Pulse 52/min B. Respiratory rate 24 C. SaO2 97% right index finger, room air D. Blood pressure 132/86 mm Hg Correct Answer C. SaO2 97% right index finger, room air The 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. A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? A. A client who just received the fourth dose of an antibiotic for an infection B. A client who has heart failure and is scheduled for discharge later in the day C. A client who is 24 hr postoperative and is visiting with friends D. A client who was recently admitted and reports chest pain Correct Answer D. A client who was recently admitted and reports chest pain The nurse should identify that a new onset of chest pain is an acute change in condition. The nurse should not delegate this task to the AP. Once the client is stable, the nurse can delegate subsequent measurement of vital signs to an AP. A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? A. Increase in blood pressure B. Decrease in respiratory rate C. Decrease in heart rate D. Increase in stroke volume Correct Answer A. Increase in blood pressure The nurse should identify that an increase in cardiac output causes an increase in the client's blood pressure. Cardiac output is the amount of blood pumped by the ventricles in 1 min. A nurse is contributing to the plan of care for a client who has hypertension. Which of the following interventions should the nurse recommend? (Select all that apply). A. Provide the client with low-sodium meals and snacks. B. Encourage the client to participate in physical activity each day. C. Instruct the client in the use of relaxation techniques.