ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
1. 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
in- cludes the measurement, the site used, and that the client is not on
oxygen.: 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
2. 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 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
3. A. Increase in blood pressure
The nurse should identify that an increase in cardiac output causes an in-
crease in the client's blood pressure. Cardiac output is the amount of blood
pumped by the ventricles in 1 min.: 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
4. A. Provide the client with low-sodium meals and snacks
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
B. Encourage the client to participate in physical activity each day.
C. Instruct the client in the use of relaxation techniques.
D. Inform the client of the importance of abstaining from using products
that contain nicotine.
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
A diet high in sodium can cause an increase in blood pressure. Therefore,
the nurse should provide the client with foods and fluids that are low in
sodium. The nurse should also provide information to the client on which
foods and fluids are high in sodium and should be avoided.
Daily physical exercise can decrease blood pressure. The nurse should en-
courage the client to participate in physical activity each day as they are
physically able.
Relaxation techniques decrease stress, lower the heart rate, and decrease
blood pressure. The nurse should instruct the client in the use of relaxation
techniques, such as guided imagery, to assist in managing hypertension.
Nicotine is a stimulant, which increases heart rate and blood pressure.
Nicotine also causes vasoconstriction, increasing blood pressure. The
nurse should provide information to the client about these effects and
encourage the client to avoid products containing nicotine. The nurse
should also refer the client to a smoking cessation program if needed.: 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.
D.Inform the client of the importance of abstaining from using products
that contain nicotine.
E. Encourage the client to increase their fluid intake to 2 L per day.
5. A. 8-year-old male: respiratory rate 34/min, SaO2 97%
The nurse should recognize that this client's respiratory rate is above the
expected reference range of 18 to 30/min for a male school-age child and
denotes tachypnea. While the SaO2 is within the expected reference
range of greater than or equal to 95%, the nurse should asses the client,
recheck
the respiratory rate, and notify the provider if the child remains tachypneic.:
A nurse is planning care for a group of clients and is reviewing the
recent vital signs obtained by an assistive personnel. From which of the
following clients should the nurse collect data and recheck the vital
signs prior to notifying the provider?
A. 8-year-old male: respiratory rate 34/min, SaO2 97%
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
B. 16-year-old female: respiratory rate 18/min SaO2 98%
2.0
1. 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
in- cludes the measurement, the site used, and that the client is not on
oxygen.: 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
2. 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 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
3. A. Increase in blood pressure
The nurse should identify that an increase in cardiac output causes an in-
crease in the client's blood pressure. Cardiac output is the amount of blood
pumped by the ventricles in 1 min.: 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
4. A. Provide the client with low-sodium meals and snacks
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
B. Encourage the client to participate in physical activity each day.
C. Instruct the client in the use of relaxation techniques.
D. Inform the client of the importance of abstaining from using products
that contain nicotine.
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
A diet high in sodium can cause an increase in blood pressure. Therefore,
the nurse should provide the client with foods and fluids that are low in
sodium. The nurse should also provide information to the client on which
foods and fluids are high in sodium and should be avoided.
Daily physical exercise can decrease blood pressure. The nurse should en-
courage the client to participate in physical activity each day as they are
physically able.
Relaxation techniques decrease stress, lower the heart rate, and decrease
blood pressure. The nurse should instruct the client in the use of relaxation
techniques, such as guided imagery, to assist in managing hypertension.
Nicotine is a stimulant, which increases heart rate and blood pressure.
Nicotine also causes vasoconstriction, increasing blood pressure. The
nurse should provide information to the client about these effects and
encourage the client to avoid products containing nicotine. The nurse
should also refer the client to a smoking cessation program if needed.: 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.
D.Inform the client of the importance of abstaining from using products
that contain nicotine.
E. Encourage the client to increase their fluid intake to 2 L per day.
5. A. 8-year-old male: respiratory rate 34/min, SaO2 97%
The nurse should recognize that this client's respiratory rate is above the
expected reference range of 18 to 30/min for a male school-age child and
denotes tachypnea. While the SaO2 is within the expected reference
range of greater than or equal to 95%, the nurse should asses the client,
recheck
the respiratory rate, and notify the provider if the child remains tachypneic.:
A nurse is planning care for a group of clients and is reviewing the
recent vital signs obtained by an assistive personnel. From which of the
following clients should the nurse collect data and recheck the vital
signs prior to notifying the provider?
A. 8-year-old male: respiratory rate 34/min, SaO2 97%
, ATI Engage Fundamentals: RN Vital Signs Assessment
2.0
B. 16-year-old female: respiratory rate 18/min SaO2 98%
