Exam (elaborations)
ATI Vital Signs (1).
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ATI Vital Signs (1).
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ATI Vital SignsFever can increase a clients respiratory rate - ANS-A Nurse is preparing an in service about
factors affecting respiratory rates for a group of assistive personnel. Which of the following
information should the nurse include?
Oral Temperature is easily accessible despite a clients position - ANS-A nurse is preparing an
in-service about vital signs for a group of newly hired AP. Which of the following info should the
nurse include about measuring body temp?
"Cardiac output is the amount of blood flow through the heart in 1 minute" - ANS-A charge nurse
is providing an in-service for a group of nurses about cardiac output. Which of the following
statements should the nurse make?
Use the thigh to obtain blood pressure when the client has severe edema in their arms. - ANS-A
nurse is discussing the use of a clients thigh for blood pressure measurements with an AP.
Which of the following info should the nurse include?
Pulmonary artery - ANS-A nurse is reviewing blood flow through the heart which a group of AP.
The nurse should identify that blood flows to which of the following parts of the heart as it leaves
the right ventricle?
Increase in blood pressure - ANS-A nurse is caring for a client who has an increase in cardiac
afterload. Which of the following findings should the nurse expect?
Toddler with respiratory rate of 44/min - ANS-A nurse is reviewing the vital signs obtained by AP
at 1200. For which of the following clients should the nurse plan to intervene?
A 23 yr old who runs marathons and has a BP of 85/54 mm Hg - ANS-A nurse is reviewing the
vital signs of four clients. The nurse should identify that which of the following clients has a vital
signs outside normal range?
Young adult with radial pulse of 56bpm - ANS-A nurse is reviewing vital signs for a group of
clients obtained by AP. The nurse should identify that which of the following requires follow up
assessment due to brachycardia?
Body temp is typically lower in older adults - ANS-A nurse is teaching a group of newly licensed
nurses about vital sign measurements. Which of the following factors should the nurse include
in teaching?
- a preschooler who was exhibiting tachypena 2hr post op and now has RR of 26/min
, -older adult who had brachycardia while sleeping now has apical pulse of 66/min
- young adult who had hypotension after an opioid analgesic and now has bp of 98/68 - ANS-A
nurse is evaluating effectiveness of interventions used for clients who had alterations in vital
signs. Which indicate interventions were effective?
Pulse deficit of 13/min - ANS-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 clients auscultated apical pulse
was 106/min and the palpated radial pulse was 93 min. The nurse should document the findings
as
A client who has stabilized BP measurments - ANS-A nurse is teaching a group of AP about
techniques used to obtain BP. For which of the following clients should the nurse instruct to
obtain an electronic BP measurement?
Smoking - ANS-A nurse is 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 client who was recently admitted and reports chest pain - ANS-A nurse is planning care for a
group of clients and is delegating to the AP to take the clients vital signs. For which of the
following clients should the nurse obtain vital signs rather than the AP?
SaO2 97% right index finger, room air - ANS-A charge nurse is reviewing documentation of vital
signs by a newly licensed nurse. Which of the following pieces of documentation is correct ?
Decrease in contractility - ANS-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 clients condition?
A 52 yr old who has SaO2 of 92% - ANS-A nurse is reviewing recent vital signs of a group of
clients. Which of the following should the nurse see first?
An adult client who received medication for pain 30 min ago and now was RR of 18/min -
ANS-A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of
interventions. Which finding indicates intervention was effective?
Low sodium meals
participate in physical activity
instruct use of relaxation techniques
abstain from nicotine - ANS-A nurse is planning care for a client who ha hypertension. Which of
the following interventions should the nurse include in the plan?
A young adult with apical pulse rate of 104/min - ANS-A nurse is reviewing the vital signs for a
group of clients which of the following should the nurse identify as tachycardia?
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