ATI VItal Signs Test Complete Questions/Answers Fall 2022/2023.

ATI VItal Signs Test Complete Questions/Answers Fall 2022/2023. A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make? a) instruct t ...

ATI VItal Signs Test Complete Questions/Answers Fall 2022/2023. A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make? a) instruct the client to increase exercise b) instruct the client to consume no more than four caffeinated beverages per day c) encourage the client to practice relaxation techniques each day d) encourage the client to engage in pattern paced breathing by panting A nurse is teaching a group of 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? a) a client who has a BP lower than the expected reference range b) a school-age client c) a client recovering from extensive abdominal surgery d) a client who has stabilized BP measurements A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? a) the AP pulls the pinna up and back when obtaining a tympanic temperature b) the AP informs the client when they are counting the respirations c) the AP gently presses down with the pads of two or three fingers over the radial pulse site d) the AP selects a blood pressure cuff that is 40% the circumference of the client's arm 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 should the nurse include? a) A client diagnosed with an elevated BP when the measurement is greater than 130/80 mm Hg b) A client us experiencing a hypertensive crisis when their BP is greater than 150/90 mm Hg c) A client who has a BP of 128/86 mm Hg has stage I hypertension d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? a) pulse 52/min b) RR 24 c) SaO2 97% right index finger, room air d) BP 132/86 mm Hg A nurse is assessing a three month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? a) count the number of beats heard in 15 seconds and multiply by 4 b) notify the provider if the apical pulse rate is greater than 110/min c) place the stethoscope over the 4th intercostal space to the left of the sternum d) auscultate the apical pulse for an S4 heart sound A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention? a) an adolescent who has a RR of 20/min b) an older adult with RR of 16/min c) an infant with RR of 52/min d) a school-age child who has a RR of 14/min A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an AP to obtain a rectal temperature? a) a toddler who has diarrhea b) a client who is 1 day post op from hemorrhoid surgery c) an infant who is receiving IV fluids d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth A nurse is reviewing the vitals for a group of clients obtained by an AP. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? a) a school-age child who has an apical pulse of 78/min b) a young adult who has a radial pulse of 56/min c) an adolescent who has a radial pulse of 76/min d) an older adult with apical pulse of 62/min A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? a) anxiety can cause a decrease in RR b) body temperature is typically lower in olde adults c) caffeine can cause a temporary decrease in pulse rate in adolescents d) BP can slightly decrease immediately following the use of nicotine A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? a) a 17 year old who has a RR of 16/min b) a young adult who has a pulse rate of 98/min c) an 11 year old who has a RR of 34/min d) an older adult who has a pulse rate of 62/min A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? a) an infant who has an apical pulse rate of 132/min b) a preschooler who has an apical pulse rate of 108/min c) a young adult who has an apical pulse rate of 104/min d) an older adult who has an apical pulse rate of 96/min A charge nurse is teaching a group of AP 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 the shift b) recording vital signs provides 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 BP measurements A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? a) apex of the heart b) right side of the sternum c) 4th intercostal space d) midclavicular line below right clavicle A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? a) "Convection is the loss of body heat when a client is in contact with a cooler surface." b) "Conduction is the loss of body heat when sweat dries from a client's skin." c) "Evaporation is the loss of body heat when a client is near a current of cool air." d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? a) instruct the client to bear down like they are having a bowel movement b) offer the client hot caffeinated tea to drink early in the morning c) hold the client's thyroid medication d) encourage the client to take a warm shower A nurse is preparing an in-service about factors affecting RR for a group of APs. Which of the following information should the nurse include? a) anxiety can decrease a client's RR b) opioid analgesics can increase a client's RR c) pain can decrease a client's RR d) Fever can increase a client's RR A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? a) increase in BP b) increase in RR c) decrease in cardiac output d decrease in preload A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? Select all that apply a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine e) anticipate a prescription for a 1L fluid bolus A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene? a) adult male who has a RR of 18/min b) toddler who has a RR of 44/min c) newborn who has a RR of 56/min d) adolescent female who has a RR of 16/min A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? a) oxygen saturation is determined by the amount of oxygen bound to WBCs b) oxygen saturation reflects the amount of oxygen being delivered to body tissues c) the expected reference range for oxygen saturation s 90% to 100% d) a capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement A charge nurse is discussing a client's RR data with a newly licensed nurse. Which of the following statements should the nurse include? a) clients will exhibit an increase in their RR after using a bronchodilator b) count the RR for 1 min who have a respiratory infection c) expect clients who have a brainstem injury to exhibit rapid respirations d) clients who are experiencing acute pain will have slow, deep respirations A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. A nurse is reviewing the vital signs fir four clients. The nurse should identify that which of the following clients has a vital sign outside of the reference range? a) a 52 year old client who has a fever due to a would infection and a pulse rate of 100/min b) a 76 year old client who reports moderate pain and has a RR of 20/min c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95% d) a 23 year old client who runs marathons and has a BP of 82/54 mm Hg A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? a) the first step in checking for checking orthostatic hypotension is obtaining a client's BP while they are standing b) an increase of 5 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension d) wait 5 minutes to check the client's BP after each position change A nurse is preparing an in-service about vital signs for a group of newly hired APs. Which of the following information should the nurse include about measuring body temperature? a) tympanic temperature can be affected by environmental temperature b) temporal temperature is inaccurate in children under 3 years old c) axillary temperature reflects rapid changes in a client's core body temperature d) oral temperature is easily accessible despite a client's position A charge nurse is evaluating a newly licensed nurse's documentation of vitals for several clients. Which of the following documentation should the charge nurse identify as being incomplete? a) radial pulse regular at 84/min b) respirations observed as even, nonlabored at 20/min with client in supine position c) BP 124/82 mm Hg lying in bed d) temporal temperature 36.9 degrees C (98.4 degrees F) A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take? a) encourage the client to change positions slowly b) restrict the client's oral intake of fluids c) encourage the client to take a short walk d) discontinue IV fluids A nurse is preparing an in-service for a group of newly hired APs about body temperature. Which of the following information should the nurse include? a) wait 5 min after a client has consumed a hot drink to obtain an oral temperature b) place a tape of patch thermometer over a client's scapula 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 A nurse is discussing the physiology of BP. Which of the following information should the nurse include? a) Diastolic BP reflects the pressure exerted during contraction of the heart b) BP is measured and documented in mm Hg c) BP decreases when blood viscosity increases d) systolic BP reflects the pressure when the heart is relaxed A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires a follow up by the nurse? a) eupnea b) dyspnea c) heart rate of 84/min d) Sao2 of 96% A nurse is discussing the use of a client's thigh for BP measurements with an AP. Which of the following information should the nurse include? a) select a blood pressure cuff width that is 25% of the circumference of the client's thigh b) palpate the femoral pulse when obtaining BP in the thigh c) expect BP in the thigh to be 10 to 15 mm Hg less than in the arm d) Use the thigh to obtain blood pressure when a client has severe edema in their arms A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? a) a client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position b) a client has a radial pulse of +4 bilateral c) an older adult client has a tympanic temperature of 35.9 degrees c (96.6 degrees f) d) a newborn has a RR of 56/min while sleeping A nurse is observing an AP who is obtaining BP reading from a client. Which of the following actions by the AP requires follow up by the nurse? a) the AP uses a cuff width that is 40% of the circumference of the client's arm b) he AP provides support for the client's arm while taking the BP c) the AP waits to take the client's BP 45 minutes after the client ambulates in the hallway d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg d) an adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min A nurse is reviewing vitals for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? a) an adult client who received medication for pan 30 min ago now has a RR of 18/min b) a school-age child who received two units of packed RBCs now has a BP of 76/54 mm Hg c) a toddler who received an antibiotic injection has a heart rate of 148/min while sleeping in their parent's arms A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vitals should the nurse identify is outside the expected reference range and notify the provider? a) a client who has an apical pulse rate of 120/min b) a client who has a BP of 100/74 mm Hg c) a client who has an apical pulse rate of 84/min d) a client who has a BP of 110/68 mm Hg A nurse is planning care for a group of clients and is reviewing the recent vitals obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? a) 16 year old female; RR 18/min, SaO2 98% b) 8 year old male; RR 34/min, SaO2 97% c) 11 year old male; RR 28/min, 99% d) 3 year old female; RR 32/min, SaO2 96% A charge nurse is reviewing the expected reference ranges of BP in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? a) hypertension is diagnosed with two elevated measurements on two separate occasions b) successive BP measurements of 126 over 78 is classified as stage I hypertension c) stage II hypertension is diagnosed when the BP measurement is 132 over 86 d) a BP measurement of 176 over 102 is classified as hypertensive crisis A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include? a) the body increases body temperature through the process known as vasodilation b) the body loses heat through shivering c) the body lowers body temperature through sweating d) the body generates heat through evaporation A nurse obtains a client's electronic BP reading of 188/96 mm Hg. Which of the following actions should the nurse take next? a) provide client teaching regarding medications to control BP b) notify the provider of the clients BP reading c) provide the client education on measurements to decrease BP d) obtain a manual BP reading from the client A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? a) AV node b) left ventricle c) SA node d) right ventricle A nurse is reviewing the recent vitals of a group of clients. Which of the following clients should the nurse see first? a) a 45 year old client who is post-op and has a BP of 130/82 b) a 28 year old client who runs marathons and has a HR of 54/min c) a 52 year old client who has an SaO2 of 92% d) a 78 year old client who has a temperature of 35.9 degrees c (96.6 degrees f) A nurse is reviewing blood flow through the heart with a group of APs. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? a) tricuspid valve b) pulmonary artery c) right atrium d) vena cava A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? a) a pulse strength of +4 indicates that the pulse is of normal strength upon palpation b) a femoral pules that is bounding upon palpation is an expected finding in a young adult c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation d) a pedal pulse that is weak upon palpation is an expected finding in an older adult a nurse is planning care for a group of clients and is delegating to the AP to take the client's vitals. For which of the following clients should the nurse obtain the vitals signs rather than the AP? a) a client who just received the fourth dose of antibiotics for an infection b) a client who has heart failure and is scheduled for a discharge later in the day c) a client who is 24 hr post-op and is visiting with friends d) a client who was recently admitted and reports chest pain A nurse s caring for a client who has a HR of 118/min. Which of the following actions should the nurse take to improve the client's HR? a) encourages the client to reduce the amount of caffeinated soft drinks b) inform the client to ambulate in the hallway for 10 min prior to taking vitals c) increase the room temperature and add blankets to warm the client d) withold the client's anti-anxiety medication A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? a) teach the client how to take their pulse so they can keep the provider informed of variations b) inform the client to ask for assistance with getting out of bed c) educate the client on medications, including therapeutic effects and potential adverse effects d) ensure the client has been taking medications as prescribes A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? a) decrease in contractility b) increase in blood viscosity c) decrease in RR d) increase in preload A nurse us 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 A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? a) BP 130/82 mm Hg left arm, lying. Client reports experiencing post-op pain as 7 on a scale of 0-10. Prescribed analgesic administered and will re-evaluate BP in 30 min b) Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in the hall c) SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 readjusted and SaO2 increased to 95% d) RR 18/min via observation, client sitting in chair A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? a) nicotine product b) opioid antagonist c) antihypertensive d) bronchodilator A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? a) a 1 month old infant who has a RR of 58/min b) a 3 year old preschooler who has an apical pulse of 144/min c) an 8 year old child who has a RR of 25/min d) an 18 month old toddler who has an apical pulse rate of 120/min A nurse is evaluating the effectiveness of interventions provided to a client who was admitted fr decreased circulation. Which of the following findings require further intervention by the nurse? a) pulse deficit of 0 b) left radial pulse is nonpalpable c) peripheral pulse +2 bilateral d) brachial pulses are symmetrical a nurse is caring for a recently admitted client and as a part of the plan of care, two nurses obtained simultaneous pulse rates. the client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following? a) pulse deficit less than 10 b) radial pulse irregular c) apical pulse greater than radial d) pulse deficit of 13/min A nurse is caring for a client who has an increase n cardiac output. Which of the following findings should the nurse expect? a) increase in BP b) decrease in RR c) decrease in HR d) increase in stroke volume - A nurse is evaluating the effectiveness of interventions used to address clients' vitals that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? a) an older adult client who has pneumonia and a RR of 26/min after a position change b) an adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesics c) a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler d) an older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? a) cardiac output is the amount of blood flow through the heart in 1 minute b) cardiac output is the amount of blood ejected from the atria c) cardiac output is the ability of the muscle fibers in the ventricles to stretch d) cardiac output is the resistance of the ventricles to pump blood through the heart