ATI Engage Fundamentals: RN Vital Signs Assessment 2.0
High-Scoring Exam Responses – Full Paper with Detailed Explanations
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 encourage 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 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%
B. 16-year-old female: respiratory rate 18/min SaO2 98%
C. 11-year-old male: respiratory rate 28/min, SaO2 99%
D. 3-year-old female: respiratory rate 32/min, SaO2 96% - 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 caring for a client who asks about factors that could cause their pulse rate to increase.
Which of the following factors should the nurse include in their response?
A. Hypothermia
B. Smoking
C. Sleeping
D. Aging - B. Smoking
Products containing nicotine, such as cigarettes, can increase pulse rate and blood pressure.
A charge nurse is teaching a group of assistive personnel (AP) about the importance of
documenting accurate vital signs. Which of the following information should the charge nurse
include in the teaching:
A. Record vital signs at the end of each shift.
B. Recording vital signs provide critical information regarding a client's condition.
C. Obtaining and documenting baseline vital signs is the responsibility of the AP.
D. It is not necessary to record electronic blood pressure measurements. - B. Recording vital
signs provides critical information regarding a client's condition.
Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the
client's currect health status and will vary according to changes in the client's health condition,
such as infection, stress, pain, or bleeding and should be recorded accurately and in a timely
manner.
A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for
a group of assistive personnel. Which of the following information should the nurse recommend
be included?
A. Fever can increase a client's respiratory rate.
B. Opioid analgesics can increase a client's respiratory rate.
C. Pain can decrease a client's respiratory rate.
, D. Anxiety can decrease a client's respiratory rate. - A. Fever can increase a client's
respiratory rate.
The nurse should include that an increased body temperature can cause an increase in a client's
respiratory rate. Other factors that can increase respiratory rate include physical exertion, chronic
lung disease, and anxiety.
A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel
(AP) about body temperature. Which of the following information should the nurse recommend
be included?
A. Wait 5 min after a client has consumed a hot drink to obtain an oral temperature.
B. Place a tape or patch thermometer over a client's spatula.
C. A tympanic thermometer reflects a client's body surface temperature.
D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. -
D. A temporal probe thermometer uses infrared scanning to determine a client's temperature.
The nurse should instruct the AP that a temporal artery thermometer uses infrared scanning to
determine the body's core temperature. The thermometer probe is placed in the center of the
forehead, swiped laterally toward the hairline, then touched to the skin behind the client's
earlobe.
A nurse is contributing to the plan of care for a client who has a temperature of 39.1 °C (102.4
°F). Which of the following interventions should the nurse include?
A. Sponge the client's skin with isopropyl alcohol.
B. Slightly increase the temperature of the client's room.
C. Offer the client hot beverages every 60 min.
D. Administer an antipyretic medication. - D. Administer an antipyretic medication.
The nurse should administer an antipyretic medication, such as acetaminophen or ibuprofen, as
prescribed to decrease body temperature. Other interventions to decrease body temperature
High-Scoring Exam Responses – Full Paper with Detailed Explanations
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 encourage 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 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%
B. 16-year-old female: respiratory rate 18/min SaO2 98%
C. 11-year-old male: respiratory rate 28/min, SaO2 99%
D. 3-year-old female: respiratory rate 32/min, SaO2 96% - 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 caring for a client who asks about factors that could cause their pulse rate to increase.
Which of the following factors should the nurse include in their response?
A. Hypothermia
B. Smoking
C. Sleeping
D. Aging - B. Smoking
Products containing nicotine, such as cigarettes, can increase pulse rate and blood pressure.
A charge nurse is teaching a group of assistive personnel (AP) about the importance of
documenting accurate vital signs. Which of the following information should the charge nurse
include in the teaching:
A. Record vital signs at the end of each shift.
B. Recording vital signs provide critical information regarding a client's condition.
C. Obtaining and documenting baseline vital signs is the responsibility of the AP.
D. It is not necessary to record electronic blood pressure measurements. - B. Recording vital
signs provides critical information regarding a client's condition.
Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the
client's currect health status and will vary according to changes in the client's health condition,
such as infection, stress, pain, or bleeding and should be recorded accurately and in a timely
manner.
A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for
a group of assistive personnel. Which of the following information should the nurse recommend
be included?
A. Fever can increase a client's respiratory rate.
B. Opioid analgesics can increase a client's respiratory rate.
C. Pain can decrease a client's respiratory rate.
, D. Anxiety can decrease a client's respiratory rate. - A. Fever can increase a client's
respiratory rate.
The nurse should include that an increased body temperature can cause an increase in a client's
respiratory rate. Other factors that can increase respiratory rate include physical exertion, chronic
lung disease, and anxiety.
A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel
(AP) about body temperature. Which of the following information should the nurse recommend
be included?
A. Wait 5 min after a client has consumed a hot drink to obtain an oral temperature.
B. Place a tape or patch thermometer over a client's spatula.
C. A tympanic thermometer reflects a client's body surface temperature.
D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. -
D. A temporal probe thermometer uses infrared scanning to determine a client's temperature.
The nurse should instruct the AP that a temporal artery thermometer uses infrared scanning to
determine the body's core temperature. The thermometer probe is placed in the center of the
forehead, swiped laterally toward the hairline, then touched to the skin behind the client's
earlobe.
A nurse is contributing to the plan of care for a client who has a temperature of 39.1 °C (102.4
°F). Which of the following interventions should the nurse include?
A. Sponge the client's skin with isopropyl alcohol.
B. Slightly increase the temperature of the client's room.
C. Offer the client hot beverages every 60 min.
D. Administer an antipyretic medication. - D. Administer an antipyretic medication.
The nurse should administer an antipyretic medication, such as acetaminophen or ibuprofen, as
prescribed to decrease body temperature. Other interventions to decrease body temperature
