RN Vital Signs Assessment (ATI) Test Questions
and Answers
A nurse is planning care for a client who is be obtained.
experiencing tachycardia. Which of the following
interventions should the nurse plan to include?
1. Instruct the client to increase exercise. A nurse is observing an assistive personnel (AP)
2. Instruct the client to consume no more than obtain vital signs from an adult client. Which of
four caffeinated beverages per day. the following actions by the AP requires follow up
3. Encourage the client to practice relaxation by the nurse?
techniques each day. 1. The AP pulls the pinna up and back when
4. Encourage the client to engage in pattern- obtaining a tympanic temperature.
paced breathing by panting. - ANSWER - 2. The AP informs the client when they are
Encourage the client to practice relaxation counting the respirations.
techniques each day. 3. The AP gently presses down with the pads of
exp:Tachycardia can be caused by stress or two to three fingers over the radial pulse site.
anxiety. The nurse should encourage the client 4. The AP selects a blood pressure cuff width
to participate in relaxation techniques such as that is 40% the circumference of the client's arm.
guided imagery, meditation, or yoga, because - ANSWER -The AP informs the client when
these can decrease heart rate and blood they are counting the respirations.
pressure. 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
A nurse is teaching a group of assistive client to alter their breathing, which can cause
personnel (AP) about techniques used to obtain inaccurate results. When obtaining vital signs, the
BP. For which of the following clients should the AP should count a client's respirations when they
nurse to instruct the AP to obtain an electronic are relaxed and at rest.
BP measurement?
1. a pt who has a BP lower than the expected
reference range A charge nurse in a clinic is preparing an in-
2. a school-age child service about blood pressure measurements for
3. a pt recovering from extensive abdominal a group of staff members. Which of the following
surgery information should the nurse include?
4. a pt who has stabilised BP measurements - 1. A client is diagnosed with an elevated blood
ANSWER -A client who has stabilized BP pressure when the measurement is greater than
measurements. 130/80 mm Hg.
exp: Blood pressure can be obtained 2. A client is experiencing a hypertensive crisis
electronically using a machine that has a blood when their blood pressure is greater than 150/90
pressure cuff attached. The machine mm Hg.
automatically inflates the bladder of the cuff and 3. A client who has a blood pressure of 128/86
displays the blood pressure on a screen. This mm Hg has stage I hypertension.
method is reserved for clients in stable condition 4. A client who has a blood pressure of 162/102
with BP measurements within the expected mm Hg has stage II hypertension. -
reference range. Manual BP measurements are ANSWER -A client who has a blood
more accurate than those obtained via an pressure of 162/102 mm Hg has stage II
electronic device, so if an abnormal reading is hypertension.
obtained electronically, a manual reading should exp: The charge nurse should include that a
, RN Vital Signs Assessment (ATI) Test Questions
and Answers
blood pressure of 162/102 mm Hg meets the
diagnostic criteria for stage II hypertension. WithA nurse is caring for a group of clients. Which of
Stage II hypertension, the systolic BP must be the following clients is experiencing an alteration
greater than 140 mm Hg and the diastolic BP in their respiratory rate that requires intervention?
must be greater than 90 mm Hg. 1. An adolescent who has a respiratory rate of
20/min
2. An older adult who has a respiratory rate of
A charge nurse is reviewing documentation of 16/min
vital signs by a newly licensed nurse. Which of 3. An infant who has a respiratory rate of 52/min
the following pieces of documentation is correct? 4. A school-age child who has a respiratory rate
1. Pulse 52/min of 14/min - ANSWER -A school-age child
2. Respiratory rate 24 who has a respiratory rate of 14/min.
3. SaO2 97% right index finger, room air exp: The nurse should identify that a respiratory
4. Blood pressure 132/86 mm Hg - rate of 14/min is below the expected reference
ANSWER -SaO2 97%, Right Index Finger, range of 18 to 30/min for a school-age child. The
Room Air child is exhibiting bradypnea, which requires
exp: The charge nurse should identify that this further data collection by the nurse.
documentation is thorough and complete and
does not require any additional information. The
information provided includes the measurement, A nurse is planning care for a group of clients.
the site used, and that the client is not on For which of the following clients should the
oxygen. nurse direct an assistive personnel (AP) to obtain
a rectal temperature?
1. A toddler who has diarrhea
A nurse is assessing a 3-month old infant during 2. A client who is 1 day postoperative following a
a well-child visit. Which of the following actions hemorrhoidectomy and receiving pain
should the nurse take when assessing the apical medications via PCA pump
pulse? 3. An infant who is receiving intravenous fluids
1. Count the number of beats heard in 15 4. A client who is diaphoretic and frequently
seconds and multiply by 4. chewing ice to relieve dry mouth -
2. Notify the provider if the apical pulse rate is ANSWER -A client who is diaphoretic an
greater than 110/min. frequently chewing ice to relieve dry mouth.
3. Place the stethoscope over the 4th intercostal exp: Oral temperatures should not be obtained in
space to the left of the sternum. clients who have consumed food or liquids or
4. Auscultate the apical pulse for an S4 heart smoked tobacco products within the previous 30
sound. - ANSWER -Place the stethoscope min. The client's diaphoresis will make it difficult
over the 4th intercostal space to the left of the to obtain an accurate temperature via the
sternum. tympanic membrane or temporal artery.
exp: The nurse should auscultate the apical Therefore, the nurse should direct the AP to
pulse over the apex of the heart, which is located obtain this client's temperature rectally.
in the 4th intercostal space to the left of the
sternum in infants and children less than 7 years
of age. A nurse is reviewing the vital signs for a group of
clients obtained by an assistive personnel. The
and Answers
A nurse is planning care for a client who is be obtained.
experiencing tachycardia. Which of the following
interventions should the nurse plan to include?
1. Instruct the client to increase exercise. A nurse is observing an assistive personnel (AP)
2. Instruct the client to consume no more than obtain vital signs from an adult client. Which of
four caffeinated beverages per day. the following actions by the AP requires follow up
3. Encourage the client to practice relaxation by the nurse?
techniques each day. 1. The AP pulls the pinna up and back when
4. Encourage the client to engage in pattern- obtaining a tympanic temperature.
paced breathing by panting. - ANSWER - 2. The AP informs the client when they are
Encourage the client to practice relaxation counting the respirations.
techniques each day. 3. The AP gently presses down with the pads of
exp:Tachycardia can be caused by stress or two to three fingers over the radial pulse site.
anxiety. The nurse should encourage the client 4. The AP selects a blood pressure cuff width
to participate in relaxation techniques such as that is 40% the circumference of the client's arm.
guided imagery, meditation, or yoga, because - ANSWER -The AP informs the client when
these can decrease heart rate and blood they are counting the respirations.
pressure. 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
A nurse is teaching a group of assistive client to alter their breathing, which can cause
personnel (AP) about techniques used to obtain inaccurate results. When obtaining vital signs, the
BP. For which of the following clients should the AP should count a client's respirations when they
nurse to instruct the AP to obtain an electronic are relaxed and at rest.
BP measurement?
1. a pt who has a BP lower than the expected
reference range A charge nurse in a clinic is preparing an in-
2. a school-age child service about blood pressure measurements for
3. a pt recovering from extensive abdominal a group of staff members. Which of the following
surgery information should the nurse include?
4. a pt who has stabilised BP measurements - 1. A client is diagnosed with an elevated blood
ANSWER -A client who has stabilized BP pressure when the measurement is greater than
measurements. 130/80 mm Hg.
exp: Blood pressure can be obtained 2. A client is experiencing a hypertensive crisis
electronically using a machine that has a blood when their blood pressure is greater than 150/90
pressure cuff attached. The machine mm Hg.
automatically inflates the bladder of the cuff and 3. A client who has a blood pressure of 128/86
displays the blood pressure on a screen. This mm Hg has stage I hypertension.
method is reserved for clients in stable condition 4. A client who has a blood pressure of 162/102
with BP measurements within the expected mm Hg has stage II hypertension. -
reference range. Manual BP measurements are ANSWER -A client who has a blood
more accurate than those obtained via an pressure of 162/102 mm Hg has stage II
electronic device, so if an abnormal reading is hypertension.
obtained electronically, a manual reading should exp: The charge nurse should include that a
, RN Vital Signs Assessment (ATI) Test Questions
and Answers
blood pressure of 162/102 mm Hg meets the
diagnostic criteria for stage II hypertension. WithA nurse is caring for a group of clients. Which of
Stage II hypertension, the systolic BP must be the following clients is experiencing an alteration
greater than 140 mm Hg and the diastolic BP in their respiratory rate that requires intervention?
must be greater than 90 mm Hg. 1. An adolescent who has a respiratory rate of
20/min
2. An older adult who has a respiratory rate of
A charge nurse is reviewing documentation of 16/min
vital signs by a newly licensed nurse. Which of 3. An infant who has a respiratory rate of 52/min
the following pieces of documentation is correct? 4. A school-age child who has a respiratory rate
1. Pulse 52/min of 14/min - ANSWER -A school-age child
2. Respiratory rate 24 who has a respiratory rate of 14/min.
3. SaO2 97% right index finger, room air exp: The nurse should identify that a respiratory
4. Blood pressure 132/86 mm Hg - rate of 14/min is below the expected reference
ANSWER -SaO2 97%, Right Index Finger, range of 18 to 30/min for a school-age child. The
Room Air child is exhibiting bradypnea, which requires
exp: The charge nurse should identify that this further data collection by the nurse.
documentation is thorough and complete and
does not require any additional information. The
information provided includes the measurement, A nurse is planning care for a group of clients.
the site used, and that the client is not on For which of the following clients should the
oxygen. nurse direct an assistive personnel (AP) to obtain
a rectal temperature?
1. A toddler who has diarrhea
A nurse is assessing a 3-month old infant during 2. A client who is 1 day postoperative following a
a well-child visit. Which of the following actions hemorrhoidectomy and receiving pain
should the nurse take when assessing the apical medications via PCA pump
pulse? 3. An infant who is receiving intravenous fluids
1. Count the number of beats heard in 15 4. A client who is diaphoretic and frequently
seconds and multiply by 4. chewing ice to relieve dry mouth -
2. Notify the provider if the apical pulse rate is ANSWER -A client who is diaphoretic an
greater than 110/min. frequently chewing ice to relieve dry mouth.
3. Place the stethoscope over the 4th intercostal exp: Oral temperatures should not be obtained in
space to the left of the sternum. clients who have consumed food or liquids or
4. Auscultate the apical pulse for an S4 heart smoked tobacco products within the previous 30
sound. - ANSWER -Place the stethoscope min. The client's diaphoresis will make it difficult
over the 4th intercostal space to the left of the to obtain an accurate temperature via the
sternum. tympanic membrane or temporal artery.
exp: The nurse should auscultate the apical Therefore, the nurse should direct the AP to
pulse over the apex of the heart, which is located obtain this client's temperature rectally.
in the 4th intercostal space to the left of the
sternum in infants and children less than 7 years
of age. A nurse is reviewing the vital signs for a group of
clients obtained by an assistive personnel. The
