RN VITAL SIGNS ASSESSMENT ATI
2025/2026//VERIFIED ANSWERS
A nurse is planning care for a client who is experiencing tachycardia. Which of the
following interventions should the nurse plan to include?
1. Instruct the client to increase exercise.
2. Instruct the client to consume no more than four caffeinated beverages per day.
3. Encourage the client to practice relaxation techniques each day.
4. Encourage the client to engage in pattern-paced breathing by panting. -
ANSWER-Encourage the client to practice relaxation techniques each day.
exp:Tachycardia can be caused by stress or anxiety. The nurse should encourage
the client to participate in relaxation techniques such as guided imagery,
meditation, or yoga, because these can decrease heart rate and blood pressure.
A nurse is teaching a group of assistive personnel (AP) about techniques used to
obtain BP. For which of the following clients should the nurse to instruct the AP to
obtain an electronic BP measurement?
1. a pt who has a BP lower than the expected reference range
2. a school-age child
3. a pt recovering from extensive abdominal surgery
4. a pt who has stabilised BP measurements - ANSWER-A client who has
stabilized BP measurements.
exp: Blood pressure can be obtained electronically using a machine that has a
blood pressure cuff attached. The machine automatically inflates the bladder of the
,cuff and displays the blood pressure on a screen. This method is reserved for
clients in stable condition with BP measurements within the expected reference
range. Manual BP measurements are more accurate than those obtained via an
electronic device, so if an abnormal reading is obtained electronically, a manual
reading should be obtained.
A nurse is observing an assistive personnel (AP) obtain vital signs from an adult
client. Which of the following actions by the AP requires follow up by the nurse?
1. The AP pulls the pinna up and back when obtaining a tympanic temperature.
2. The AP informs the client when they are counting the respirations.
3. The AP gently presses down with the pads of two to three fingers over the radial
pulse site.
4. The AP selects a blood pressure cuff width that is 40% the circumference of the
client's arm. - ANSWER-The AP informs the client when they are counting the
respirations.
exp: According to evidence-based practice, the AP should not inform the client
they are going to count their respirations. This action can lead the client to alter
their breathing, which can cause inaccurate results. When obtaining vital signs, the
AP should count a client's respirations when they are relaxed and at rest.
A charge nurse in a clinic is preparing an in-service about blood pressure
measurements for a group of staff members. Which of the following information
should the nurse include?
1. A client is diagnosed with an elevated blood pressure when the measurement is
greater than 130/80 mm Hg.
2. A client is experiencing a hypertensive crisis when their blood pressure is greater
than 150/90 mm Hg.
3. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension.
, 4. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. -
ANSWER-A client who has a blood pressure of 162/102 mm Hg has stage II
hypertension.
exp: The charge nurse should include that a blood pressure of 162/102 mm Hg
meets the diagnostic criteria for stage II hypertension. With Stage II hypertension,
the systolic BP must be greater than 140 mm Hg and the diastolic BP must be
greater than 90 mm Hg.
A charge nurse is reviewing documentation of vital signs by a newly licensed
nurse. Which of the following pieces of documentation is correct?
1. Pulse 52/min
2. Respiratory rate 24
3. SaO2 97% right index finger, room air
4. Blood pressure 132/86 mm Hg - ANSWER-SaO2 97%, Right Index Finger,
Room Air
exp: The charge nurse should identify that this documentation is thorough and
complete and does not require any additional information. The information
provided includes the measurement, the site used, and that the client is not on
oxygen.
A nurse is assessing a 3-month old infant during a well-child visit. Which of the
following actions should the nurse take when assessing the apical pulse?
1. Count the number of beats heard in 15 seconds and multiply by 4.
2. Notify the provider if the apical pulse rate is greater than 110/min.
3. Place the stethoscope over the 4th intercostal space to the left of the sternum.
4. Auscultate the apical pulse for an S4 heart sound. - ANSWER-Place the
stethoscope over the 4th intercostal space to the left of the sternum.
2025/2026//VERIFIED ANSWERS
A nurse is planning care for a client who is experiencing tachycardia. Which of the
following interventions should the nurse plan to include?
1. Instruct the client to increase exercise.
2. Instruct the client to consume no more than four caffeinated beverages per day.
3. Encourage the client to practice relaxation techniques each day.
4. Encourage the client to engage in pattern-paced breathing by panting. -
ANSWER-Encourage the client to practice relaxation techniques each day.
exp:Tachycardia can be caused by stress or anxiety. The nurse should encourage
the client to participate in relaxation techniques such as guided imagery,
meditation, or yoga, because these can decrease heart rate and blood pressure.
A nurse is teaching a group of assistive personnel (AP) about techniques used to
obtain BP. For which of the following clients should the nurse to instruct the AP to
obtain an electronic BP measurement?
1. a pt who has a BP lower than the expected reference range
2. a school-age child
3. a pt recovering from extensive abdominal surgery
4. a pt who has stabilised BP measurements - ANSWER-A client who has
stabilized BP measurements.
exp: Blood pressure can be obtained electronically using a machine that has a
blood pressure cuff attached. The machine automatically inflates the bladder of the
,cuff and displays the blood pressure on a screen. This method is reserved for
clients in stable condition with BP measurements within the expected reference
range. Manual BP measurements are more accurate than those obtained via an
electronic device, so if an abnormal reading is obtained electronically, a manual
reading should be obtained.
A nurse is observing an assistive personnel (AP) obtain vital signs from an adult
client. Which of the following actions by the AP requires follow up by the nurse?
1. The AP pulls the pinna up and back when obtaining a tympanic temperature.
2. The AP informs the client when they are counting the respirations.
3. The AP gently presses down with the pads of two to three fingers over the radial
pulse site.
4. The AP selects a blood pressure cuff width that is 40% the circumference of the
client's arm. - ANSWER-The AP informs the client when they are counting the
respirations.
exp: According to evidence-based practice, the AP should not inform the client
they are going to count their respirations. This action can lead the client to alter
their breathing, which can cause inaccurate results. When obtaining vital signs, the
AP should count a client's respirations when they are relaxed and at rest.
A charge nurse in a clinic is preparing an in-service about blood pressure
measurements for a group of staff members. Which of the following information
should the nurse include?
1. A client is diagnosed with an elevated blood pressure when the measurement is
greater than 130/80 mm Hg.
2. A client is experiencing a hypertensive crisis when their blood pressure is greater
than 150/90 mm Hg.
3. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension.
, 4. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. -
ANSWER-A client who has a blood pressure of 162/102 mm Hg has stage II
hypertension.
exp: The charge nurse should include that a blood pressure of 162/102 mm Hg
meets the diagnostic criteria for stage II hypertension. With Stage II hypertension,
the systolic BP must be greater than 140 mm Hg and the diastolic BP must be
greater than 90 mm Hg.
A charge nurse is reviewing documentation of vital signs by a newly licensed
nurse. Which of the following pieces of documentation is correct?
1. Pulse 52/min
2. Respiratory rate 24
3. SaO2 97% right index finger, room air
4. Blood pressure 132/86 mm Hg - ANSWER-SaO2 97%, Right Index Finger,
Room Air
exp: The charge nurse should identify that this documentation is thorough and
complete and does not require any additional information. The information
provided includes the measurement, the site used, and that the client is not on
oxygen.
A nurse is assessing a 3-month old infant during a well-child visit. Which of the
following actions should the nurse take when assessing the apical pulse?
1. Count the number of beats heard in 15 seconds and multiply by 4.
2. Notify the provider if the apical pulse rate is greater than 110/min.
3. Place the stethoscope over the 4th intercostal space to the left of the sternum.
4. Auscultate the apical pulse for an S4 heart sound. - ANSWER-Place the
stethoscope over the 4th intercostal space to the left of the sternum.
