RN Vital Signs Assessment (ATI) Exam Questions with Correct Answers 100% Verified|
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A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma.
Which of the following medications should the nurse anticipate administering?
1. a nicotine product
2. an opioid antagonist
3. an antihypertensive
4. a bronchodilator A bronchodilator
exp: Tachypnea occurs during an asthma attack due to a constriction in the airways, leading to a
decrease in oxygenation. The respiratory rate increases to compensate for the decrease in
oxygen to the tissues. A bronchodilator decreases inflammation in the lungs, which opens the
airways. This allows for improved oxygenation to the tissues, thereby decreasing the respiratory
rate.
A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the
following clients has a vital sign outside the expected reference range and requires
intervention?
1. A 1-month-old infant who has a respiratory rate of 58/min
2. A 3-year-old preschooler who has an apical pulse rate of 144/min
3. An 8-year-old child who has a respiratory rate of 25/min
4. An 18-month-old toddler who has an apical pulse rate of 120/min A 3-year-old
preschooler who has an apical pulse rate of 144/min.
exp: The nurse should identify that an apical pulse rate of 144/min is above the expected
reference range of 75 to 129/min for a preschooler. This finding requires intervention by the
nurse.
A nurse is evaluating the effectiveness of interventions provided to a client who was admitted
for decreased circulation. Which of the following findings requires further intervention by the
nurse?
,1. Pulse deficit of 0
2. Left radial pulse is nonpalpable
3. Peripheral pulse +2 bilateral
4. Brachial pulses are symmetrical Left radial pulse is nonpalpable
exp: Peripheral pulses that are nonpalpable require further intervention by the nurse. The
nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. The nurse should
also determine if the client has other manifestations of impaired circulation, such as cool, pale
skin. The nurse should notify the provider of any unexpected findings.
A nurse is caring for a recently admitted client and as part of the plan of care, two nurses
obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the
palpated radial pulse was 93/min. The nurse should document the findings as which of the
following?
1. Pulse deficit less than 10
2. Radial pulse irregular
3.Apical pulse greater than radial
4. Pulse deficit of 13/min Pulse deficit of 13/min
exp: A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse
(usually the radial) for 1 min time. This can be caused by atrial fibrillation, aortic rupture, or
coronary artery disease. The nurse should document the findings in the client's medical record
and notify the provider if a pulse deficit is present.
A nurse is caring for a client who has an increase in cardiac output. Which of the following
findings should the nurse expect?
1. Increase in blood pressure
2. Decrease in respiratory rate
3. Decrease in heart rate
4. Increase in stroke volume Increase in blood pressure
, exp: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 evaluating the effectiveness of interventions used to address clients' vital signs that
were outside of the expected references ranges. Which of the following findings indicates the
intervention was effective?
1. An older adult client who has pneumonia and a respiratory rate of 26/min after a position
change
2. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid
analgesic
3. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm
Hg after using an inhaler
4. An older adult client who has an infection and a pulse rate of 110/min after using relaxation
techniques A young adult who is experiencing an asthma attack and has a blood pressure of
116/72 mm Hg after using an inhaler.
exp: The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected
reference range for a young adult. The expected systolic blood pressure should be less than 120
mm Hg and the diastolic blood pressure should be less than 80 mm Hg. Therefore, the
intervention of using an inhaler was effective.
A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of
the following statements should the nurse include?
1. "Cardiac output is the amount of blood flow through the heart in 1 minute."
2. "Cardiac output is the amount of blood ejected from the atria."
3. "Cardiac output is the ability of the muscle fibers in the ventricles to stretch."
4. "Cardiac output is the resistance of the ventricles to pump blood through the heart."
"Cardiac output is the amount of blood flow through the heart in 1 minute."
A nurse is planning care for a client who is experiencing tachycardia. Which of the following
interventions should the nurse plan to include?
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A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma.
Which of the following medications should the nurse anticipate administering?
1. a nicotine product
2. an opioid antagonist
3. an antihypertensive
4. a bronchodilator A bronchodilator
exp: Tachypnea occurs during an asthma attack due to a constriction in the airways, leading to a
decrease in oxygenation. The respiratory rate increases to compensate for the decrease in
oxygen to the tissues. A bronchodilator decreases inflammation in the lungs, which opens the
airways. This allows for improved oxygenation to the tissues, thereby decreasing the respiratory
rate.
A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the
following clients has a vital sign outside the expected reference range and requires
intervention?
1. A 1-month-old infant who has a respiratory rate of 58/min
2. A 3-year-old preschooler who has an apical pulse rate of 144/min
3. An 8-year-old child who has a respiratory rate of 25/min
4. An 18-month-old toddler who has an apical pulse rate of 120/min A 3-year-old
preschooler who has an apical pulse rate of 144/min.
exp: The nurse should identify that an apical pulse rate of 144/min is above the expected
reference range of 75 to 129/min for a preschooler. This finding requires intervention by the
nurse.
A nurse is evaluating the effectiveness of interventions provided to a client who was admitted
for decreased circulation. Which of the following findings requires further intervention by the
nurse?
,1. Pulse deficit of 0
2. Left radial pulse is nonpalpable
3. Peripheral pulse +2 bilateral
4. Brachial pulses are symmetrical Left radial pulse is nonpalpable
exp: Peripheral pulses that are nonpalpable require further intervention by the nurse. The
nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. The nurse should
also determine if the client has other manifestations of impaired circulation, such as cool, pale
skin. The nurse should notify the provider of any unexpected findings.
A nurse is caring for a recently admitted client and as part of the plan of care, two nurses
obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the
palpated radial pulse was 93/min. The nurse should document the findings as which of the
following?
1. Pulse deficit less than 10
2. Radial pulse irregular
3.Apical pulse greater than radial
4. Pulse deficit of 13/min Pulse deficit of 13/min
exp: A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse
(usually the radial) for 1 min time. This can be caused by atrial fibrillation, aortic rupture, or
coronary artery disease. The nurse should document the findings in the client's medical record
and notify the provider if a pulse deficit is present.
A nurse is caring for a client who has an increase in cardiac output. Which of the following
findings should the nurse expect?
1. Increase in blood pressure
2. Decrease in respiratory rate
3. Decrease in heart rate
4. Increase in stroke volume Increase in blood pressure
, exp: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 evaluating the effectiveness of interventions used to address clients' vital signs that
were outside of the expected references ranges. Which of the following findings indicates the
intervention was effective?
1. An older adult client who has pneumonia and a respiratory rate of 26/min after a position
change
2. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid
analgesic
3. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm
Hg after using an inhaler
4. An older adult client who has an infection and a pulse rate of 110/min after using relaxation
techniques A young adult who is experiencing an asthma attack and has a blood pressure of
116/72 mm Hg after using an inhaler.
exp: The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected
reference range for a young adult. The expected systolic blood pressure should be less than 120
mm Hg and the diastolic blood pressure should be less than 80 mm Hg. Therefore, the
intervention of using an inhaler was effective.
A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of
the following statements should the nurse include?
1. "Cardiac output is the amount of blood flow through the heart in 1 minute."
2. "Cardiac output is the amount of blood ejected from the atria."
3. "Cardiac output is the ability of the muscle fibers in the ventricles to stretch."
4. "Cardiac output is the resistance of the ventricles to pump blood through the heart."
"Cardiac output is the amount of blood flow through the heart in 1 minute."
A nurse is planning care for a client who is experiencing tachycardia. Which of the following
interventions should the nurse plan to include?
