ATI module vital signs test Questions with Correct Answers 100% Verified|
Guaranteed Success
A nurse is collecting data about a client's respiratory condition. Which of the following actions
should the nurse take to determine the depth of the client's respiration. Observe the degree
of the chest-wall movement during inspiration and expiration.
The nurse can determine the depth of respiration subjectively by evaluating how much chest-
wall movement is observed. The movement is generated by the movements of the diaphragm
and intercostal muscles as the client breathes. With shallow respiration, the nurse will observe
very little movement. Deep respiration involves full expansion of the lungs, which is usually
quite visible.
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for
the nurse to report to the provider? Respirations 30/min
Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the
need for immediate attention. An adult client who has respirations of 30/min is experiencing
shortness of breath, or dyspnea. Without intervention, this can become a life-threatening
situation.
A nurse is preparing to record the difference between a client's systolic and diastolic blood
pressure. Which of the following terms defines this information when documenting? Pulse
pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the client's
blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a
predictor of heart conditions, especially in older adults. For example, an elevated pulse
pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to
hypertension or atherosclerosis.
, A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart
sounds are heard when which of the following occurs? When the semilunar valves close
The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or
semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub"
sound.
A nurse is preparing to obtain a clients blood pressure. Which of the following actions should
the nurse take to measure the blood pressure accurately? Use a cuff of the appropriate size
for the client
Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is too
small will result in a reading that is falsely high and using a cuff that is too big will record a false
low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm
circumference where the cuff will be wrapped. The bladder, which is inside the cuff, should
surround 80% of the arm circumference.
A nurse is assessing a client's respiration. Which of the following actions should the nurse take?
Elevate the head of the clients bed 45 degree to 60 degree.
This is a comfortable position for most clients and it allows full ventilatory movement.
Discomfort can increase a client's respiratory rate.
A nurse is measuring a client's temperature orally. Which of the following actions should the
nurse take? Place the probe in the posterior lingual pocket lateral to there midline.
The heat produced by superficial blood vessels in the right and the left posterior sublingual
pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways"
into the back of the area under the tongue on the left or the right will access this area.
Guaranteed Success
A nurse is collecting data about a client's respiratory condition. Which of the following actions
should the nurse take to determine the depth of the client's respiration. Observe the degree
of the chest-wall movement during inspiration and expiration.
The nurse can determine the depth of respiration subjectively by evaluating how much chest-
wall movement is observed. The movement is generated by the movements of the diaphragm
and intercostal muscles as the client breathes. With shallow respiration, the nurse will observe
very little movement. Deep respiration involves full expansion of the lungs, which is usually
quite visible.
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for
the nurse to report to the provider? Respirations 30/min
Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the
need for immediate attention. An adult client who has respirations of 30/min is experiencing
shortness of breath, or dyspnea. Without intervention, this can become a life-threatening
situation.
A nurse is preparing to record the difference between a client's systolic and diastolic blood
pressure. Which of the following terms defines this information when documenting? Pulse
pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the client's
blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a
predictor of heart conditions, especially in older adults. For example, an elevated pulse
pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to
hypertension or atherosclerosis.
, A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart
sounds are heard when which of the following occurs? When the semilunar valves close
The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or
semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub"
sound.
A nurse is preparing to obtain a clients blood pressure. Which of the following actions should
the nurse take to measure the blood pressure accurately? Use a cuff of the appropriate size
for the client
Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is too
small will result in a reading that is falsely high and using a cuff that is too big will record a false
low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm
circumference where the cuff will be wrapped. The bladder, which is inside the cuff, should
surround 80% of the arm circumference.
A nurse is assessing a client's respiration. Which of the following actions should the nurse take?
Elevate the head of the clients bed 45 degree to 60 degree.
This is a comfortable position for most clients and it allows full ventilatory movement.
Discomfort can increase a client's respiratory rate.
A nurse is measuring a client's temperature orally. Which of the following actions should the
nurse take? Place the probe in the posterior lingual pocket lateral to there midline.
The heat produced by superficial blood vessels in the right and the left posterior sublingual
pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways"
into the back of the area under the tongue on the left or the right will access this area.
