10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
RN Vital Signs Assessment (ATI) UPDATED VERSION
WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS \VERIFIED ANSWERS \LATEST
UPDATE 2025-2026
A nurse is observing an The AP informs the client when they are counting the
assistive personnel (AP) respirations.
exp: According to evidence-based practice, the AP
obtain vital signs from an
should not inform the client they are going to count
adult client. Which of the
their respirations. This action can lead the client to alter
following actions by the AP
their
requires follow up by the
breathing, which can cause inaccurate results. When
nurse?
obtaining vital signs, the AP should count a client's
1. The AP pulls the pinna up
respirations when they are relaxed and at rest.
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.
/ 1/39
,10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A charge nurse in a clinic is A client who has a blood pressure of 162/102 mm Hg has stage II
preparing an in-service hypertension.
exp: The charge nurse should include that a blood
about blood pressure
pressure of 162/102 mm Hg meets the diagnostic
measurements for a group
criteria for stage II hypertension. With Stage II
of staff members. Which of
hypertension, the systolic BP must be greater than 140
the following
information should the nurse mm Hg and the diastolic BP must be greater than 90
include?
mm Hg.
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.
A charge nurse is reviewing SaO2 97%, Right Index Finger, Room Air
documentation of vital exp: The charge nurse should identify that this documentation is
thorough and
signs by a newly licensed
complete and does not require any additional
nurse.
information. The information provided includes the
Which of the following
measurement, the site used, and that the client is not
pieces of documentation
on oxygen.
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
/ 2/39
,10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A nurse is assessing a 3- Place the stethoscope over the 4th intercostal space to the left of
month old infant during a the sternum.
exp: The nurse should auscultate the apical pulse over
well-child visit. Which of
the apex of the heart, which is located in the 4th
the
intercostal space to the left of the sternum in infants
following actions should the
and children less than 7 years of age.
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.
/ 3/39
, 10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A nurse is caring for a group A school-age child who has a respiratory rate of 14/min.
of clients. exp: The nurse should identify that a respiratory rate of
Which of the 14/min is below the expected reference range of 18 to
following clients is 30/min for a school-age child. The child is exhibiting
experiencing an bradypnea, which requires further data collection by the nurse.
alteration in their
respiratory rate that requires
intervention?
1. An adolescent who has a
respiratory rate of 20/min
2. An older adult who has a
respiratory rate of 16/min
3. An infant who has a
respiratory rate of 52/min
4. A school-age child who has
a respiratory rate of
14/min
A nurse is planning care for a A client who is diaphoretic an frequently chewing ice to relieve
group of dry mouth.
clients. For which of the exp: Oral temperatures should not be obtained in
following clients should the clients who have consumed food or liquids or smoked
nurse direct an assistive tobacco products within the previous 30 min. The
personnel (AP) to obtain a client's
rectal temperature? diaphoresis will make it difficult to obtain an accurate
1. A toddler who has diarrhea
temperature via the tympanic membrane or temporal
2. A client who is 1 day
artery. Therefore, the nurse should direct the AP to
postoperative following
obtain this client's temperature rectally.
a hemorrhoidectomy
and
receiving pain medications via
PCA pump
3. An infant who is
receiving intravenous
fluids
4. A client who is diaphoretic
and
frequently chewing ice to
relieve dry mouth
/ 4/39
RN Vital Signs Assessment (ATI) UPDATED VERSION
WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS \VERIFIED ANSWERS \LATEST
UPDATE 2025-2026
A nurse is observing an The AP informs the client when they are counting the
assistive personnel (AP) respirations.
exp: According to evidence-based practice, the AP
obtain vital signs from an
should not inform the client they are going to count
adult client. Which of the
their respirations. This action can lead the client to alter
following actions by the AP
their
requires follow up by the
breathing, which can cause inaccurate results. When
nurse?
obtaining vital signs, the AP should count a client's
1. The AP pulls the pinna up
respirations when they are relaxed and at rest.
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.
/ 1/39
,10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A charge nurse in a clinic is A client who has a blood pressure of 162/102 mm Hg has stage II
preparing an in-service hypertension.
exp: The charge nurse should include that a blood
about blood pressure
pressure of 162/102 mm Hg meets the diagnostic
measurements for a group
criteria for stage II hypertension. With Stage II
of staff members. Which of
hypertension, the systolic BP must be greater than 140
the following
information should the nurse mm Hg and the diastolic BP must be greater than 90
include?
mm Hg.
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.
A charge nurse is reviewing SaO2 97%, Right Index Finger, Room Air
documentation of vital exp: The charge nurse should identify that this documentation is
thorough and
signs by a newly licensed
complete and does not require any additional
nurse.
information. The information provided includes the
Which of the following
measurement, the site used, and that the client is not
pieces of documentation
on oxygen.
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
/ 2/39
,10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A nurse is assessing a 3- Place the stethoscope over the 4th intercostal space to the left of
month old infant during a the sternum.
exp: The nurse should auscultate the apical pulse over
well-child visit. Which of
the apex of the heart, which is located in the 4th
the
intercostal space to the left of the sternum in infants
following actions should the
and children less than 7 years of age.
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.
/ 3/39
, 10/31/25, 8:28 PM RN Vital Signs Assessment (ATI)
A nurse is caring for a group A school-age child who has a respiratory rate of 14/min.
of clients. exp: The nurse should identify that a respiratory rate of
Which of the 14/min is below the expected reference range of 18 to
following clients is 30/min for a school-age child. The child is exhibiting
experiencing an bradypnea, which requires further data collection by the nurse.
alteration in their
respiratory rate that requires
intervention?
1. An adolescent who has a
respiratory rate of 20/min
2. An older adult who has a
respiratory rate of 16/min
3. An infant who has a
respiratory rate of 52/min
4. A school-age child who has
a respiratory rate of
14/min
A nurse is planning care for a A client who is diaphoretic an frequently chewing ice to relieve
group of dry mouth.
clients. For which of the exp: Oral temperatures should not be obtained in
following clients should the clients who have consumed food or liquids or smoked
nurse direct an assistive tobacco products within the previous 30 min. The
personnel (AP) to obtain a client's
rectal temperature? diaphoresis will make it difficult to obtain an accurate
1. A toddler who has diarrhea
temperature via the tympanic membrane or temporal
2. A client who is 1 day
artery. Therefore, the nurse should direct the AP to
postoperative following
obtain this client's temperature rectally.
a hemorrhoidectomy
and
receiving pain medications via
PCA pump
3. An infant who is
receiving intravenous
fluids
4. A client who is diaphoretic
and
frequently chewing ice to
relieve dry mouth
/ 4/39
