RN Vital Signs Assessment (ATI)
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
When assessing blood pressure, what should the nurse do if the first reading is elevated?
✔✔A. Wait 1-2 minutes and take the reading again
B. Take the reading again immediately
C. Notify the provider without retaking the reading
D. Recheck the blood pressure every 15 minutes
What is the primary purpose of measuring oxygen saturation with a pulse oximeter?
A. To assess respiratory rate
✔✔B. To determine the percentage of oxygen in the blood
C. To assess circulation
D. To measure heart rate
What action should be taken if a client reports pain during a vital sign check?
A. Continue with the assessment as normal
✔✔B. Document the pain and assess the pain level separately
1
,C. Skip the pain assessment and move to the next step
D. Immediately call for assistance from another nurse
Which of the following is true regarding blood pressure measurement?
A. Blood pressure should be taken immediately after physical activity
B. A higher cuff size results in a lower reading
✔✔C. Blood pressure readings should be taken with the client seated with feet flat on the floor
D. A lower cuff size results in a more accurate reading
What is considered a normal range for a newborn’s heart rate?
✔✔A. 120 to 160 bpm
B. 80 to 100 bpm
C. 100 to 120 bpm
D. 60 to 80 bpm
What should the nurse do if the client’s blood pressure is 160/110 mmHg on the first
measurement?
✔✔A. Recheck the blood pressure after a few minutes
2
,B. Notify the healthcare provider immediately and document the reading
C. Ignore it as a one-time occurrence
D. Apply ice packs to the arms to lower the reading
What is the correct action if a pulse oximeter reading is below 90%?
A. Turn off the machine and restart
✔✔B. Check the placement of the sensor and assess the patient’s clinical status
C. Increase the oxygen flow rate
D. Administer pain medication immediately
What is the correct method for measuring oral temperature in an adult?
A. Place the thermometer under the tongue and have the patient breathe through their nose
✔✔B. Place the thermometer under the tongue and have the patient close their mouth
C. Ask the patient to chew gum before taking the temperature
D. Place the thermometer under the tongue with the mouth slightly open
What is the correct method for measuring blood pressure in a patient with an IV in the arm?
✔✔A. Use the opposite arm if possible
3
, B. Measure the blood pressure through the IV arm
C. Apply a larger cuff over the IV site
D. Measure the blood pressure at the thigh
Which is the best way to assess the respiratory rate of a pediatric patient?
✔✔A. Observe the chest rise and fall for one full minute
B. Count the breaths for 30 seconds and multiply by 2
C. Count breaths while the child is playing
D. Ask the child to breathe in and out deeply
What is an acceptable range for a toddler's respiratory rate?
A. 8 to 12 breaths per minute
B. 12 to 16 breaths per minute
✔✔C. 20 to 30 breaths per minute
D. 30 to 40 breaths per minute
What is the normal range for an adult’s blood pressure?
A. 90/60 to 120/80 mmHg
4
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
When assessing blood pressure, what should the nurse do if the first reading is elevated?
✔✔A. Wait 1-2 minutes and take the reading again
B. Take the reading again immediately
C. Notify the provider without retaking the reading
D. Recheck the blood pressure every 15 minutes
What is the primary purpose of measuring oxygen saturation with a pulse oximeter?
A. To assess respiratory rate
✔✔B. To determine the percentage of oxygen in the blood
C. To assess circulation
D. To measure heart rate
What action should be taken if a client reports pain during a vital sign check?
A. Continue with the assessment as normal
✔✔B. Document the pain and assess the pain level separately
1
,C. Skip the pain assessment and move to the next step
D. Immediately call for assistance from another nurse
Which of the following is true regarding blood pressure measurement?
A. Blood pressure should be taken immediately after physical activity
B. A higher cuff size results in a lower reading
✔✔C. Blood pressure readings should be taken with the client seated with feet flat on the floor
D. A lower cuff size results in a more accurate reading
What is considered a normal range for a newborn’s heart rate?
✔✔A. 120 to 160 bpm
B. 80 to 100 bpm
C. 100 to 120 bpm
D. 60 to 80 bpm
What should the nurse do if the client’s blood pressure is 160/110 mmHg on the first
measurement?
✔✔A. Recheck the blood pressure after a few minutes
2
,B. Notify the healthcare provider immediately and document the reading
C. Ignore it as a one-time occurrence
D. Apply ice packs to the arms to lower the reading
What is the correct action if a pulse oximeter reading is below 90%?
A. Turn off the machine and restart
✔✔B. Check the placement of the sensor and assess the patient’s clinical status
C. Increase the oxygen flow rate
D. Administer pain medication immediately
What is the correct method for measuring oral temperature in an adult?
A. Place the thermometer under the tongue and have the patient breathe through their nose
✔✔B. Place the thermometer under the tongue and have the patient close their mouth
C. Ask the patient to chew gum before taking the temperature
D. Place the thermometer under the tongue with the mouth slightly open
What is the correct method for measuring blood pressure in a patient with an IV in the arm?
✔✔A. Use the opposite arm if possible
3
, B. Measure the blood pressure through the IV arm
C. Apply a larger cuff over the IV site
D. Measure the blood pressure at the thigh
Which is the best way to assess the respiratory rate of a pediatric patient?
✔✔A. Observe the chest rise and fall for one full minute
B. Count the breaths for 30 seconds and multiply by 2
C. Count breaths while the child is playing
D. Ask the child to breathe in and out deeply
What is an acceptable range for a toddler's respiratory rate?
A. 8 to 12 breaths per minute
B. 12 to 16 breaths per minute
✔✔C. 20 to 30 breaths per minute
D. 30 to 40 breaths per minute
What is the normal range for an adult’s blood pressure?
A. 90/60 to 120/80 mmHg
4
