ATI RN FUNDAMENTALS vital signs EXAM 2025 ACTUAL
EXAM COMPLETE QUESTIONS WITH DETAILED VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
A+
1.A nurse is evaluating the effectiveness of interventions provided to four
clients who have unexpected findings for vital signs. Which of the
following findings requires follow up?
A. A client that has 8 mm Hg difference in systolic BP when moving from a
sitting to a standing position.
B. A client has a radial pulse of +4 bilateral.
C. An older adult client has a tympanic temperature of 35.9 C (96.6 F).
D. A newborn has a respiratory rate of 56/min while sleeping.: B. A client has
a radial pulse of +4 bilateral.
Rationale: A peripheral pulse strength of +4 is described as bounding an
is considered an unexpected finding. The nurse should check further and
report the findings to the provider. A pulse strength of +2 is considered
an expected finding.
2.A nurse is providing care to a client who has an apical pulse rate of
54/min and is experiencing dizziness. Which of the following is the nurse's
priority action?
A. Teach the client how to take their pulse so they can keep the
provider informed of variations.
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, B. Inform the client to ask for assistance with getting out of bed.
C. Educate the client on medications, including therapeutic effects and
poten- tial adverse effects.
D. Ensure the client has been taking medications as prescribed.: B. Inform
the client to ask for assistance with getting out of bed.
Rationale: Bradycardia associated with dizziness indicates the greatest
risk to this client is injury due to a fall; therefore this is the priority action
by the nurse.
3.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?
A. Anxiety can decrease a client's respiration rate.
B. Opioid analgesics can increase a client's respiratory rate.
C. Pain can decrease a client's respiratory rate.
D. Fever can increase a client's respiratory rate.: D. Fever can increase a
client's respiratory rate.
Rationale: The nurse should include that an increased body temperature
can cause
To get this or any other Exam contact ()
, an increase in a client's respiratory rate. Other factors that can increase
respiratory rates include physical exertion, chronic lung disease, and
anxiety.
4.A nurse is obtaining vital signs for a group of clients. Which of the
following findings requires intervention?
A. A 17-year-old who has a respiratory rate of 16/min.
B. A young adult who has a pulse rate of 98/min.
C. An 11-year-old child who has a respiratory rate of 34/min.
D. An older adult who has a pulse rate of 62/min.: C. An 11-year-old child
who has a respiratory rate of 34/min
Rationale: The nurse should identify that a respiratory rate of 34/min is
above the expected reference range of 18 to 30/min for a school-age
child. This finding requires intervention by the nurse.
5.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.: D. A client
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, who was recently admitted and reports chest pain.
Rationale: 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.
6.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?
A. Apex of the heart.
B. Right side of sternum.
C. 4th intercostal space.
D. Mid-clavicular line below right clavicle: A. Apex of the heart
Rationale: The nurse should identify that the apical pulse is auscultated
over the
To get this or any other Exam contact ()
EXAM COMPLETE QUESTIONS WITH DETAILED VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
A+
1.A nurse is evaluating the effectiveness of interventions provided to four
clients who have unexpected findings for vital signs. Which of the
following findings requires follow up?
A. A client that has 8 mm Hg difference in systolic BP when moving from a
sitting to a standing position.
B. A client has a radial pulse of +4 bilateral.
C. An older adult client has a tympanic temperature of 35.9 C (96.6 F).
D. A newborn has a respiratory rate of 56/min while sleeping.: B. A client has
a radial pulse of +4 bilateral.
Rationale: A peripheral pulse strength of +4 is described as bounding an
is considered an unexpected finding. The nurse should check further and
report the findings to the provider. A pulse strength of +2 is considered
an expected finding.
2.A nurse is providing care to a client who has an apical pulse rate of
54/min and is experiencing dizziness. Which of the following is the nurse's
priority action?
A. Teach the client how to take their pulse so they can keep the
provider informed of variations.
To get this or any other Exam contact ()
, B. Inform the client to ask for assistance with getting out of bed.
C. Educate the client on medications, including therapeutic effects and
poten- tial adverse effects.
D. Ensure the client has been taking medications as prescribed.: B. Inform
the client to ask for assistance with getting out of bed.
Rationale: Bradycardia associated with dizziness indicates the greatest
risk to this client is injury due to a fall; therefore this is the priority action
by the nurse.
3.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?
A. Anxiety can decrease a client's respiration rate.
B. Opioid analgesics can increase a client's respiratory rate.
C. Pain can decrease a client's respiratory rate.
D. Fever can increase a client's respiratory rate.: D. Fever can increase a
client's respiratory rate.
Rationale: The nurse should include that an increased body temperature
can cause
To get this or any other Exam contact ()
, an increase in a client's respiratory rate. Other factors that can increase
respiratory rates include physical exertion, chronic lung disease, and
anxiety.
4.A nurse is obtaining vital signs for a group of clients. Which of the
following findings requires intervention?
A. A 17-year-old who has a respiratory rate of 16/min.
B. A young adult who has a pulse rate of 98/min.
C. An 11-year-old child who has a respiratory rate of 34/min.
D. An older adult who has a pulse rate of 62/min.: C. An 11-year-old child
who has a respiratory rate of 34/min
Rationale: The nurse should identify that a respiratory rate of 34/min is
above the expected reference range of 18 to 30/min for a school-age
child. This finding requires intervention by the nurse.
5.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.: D. A client
To get this or any other Exam contact ()
, who was recently admitted and reports chest pain.
Rationale: 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.
6.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?
A. Apex of the heart.
B. Right side of sternum.
C. 4th intercostal space.
D. Mid-clavicular line below right clavicle: A. Apex of the heart
Rationale: The nurse should identify that the apical pulse is auscultated
over the
To get this or any other Exam contact ()
