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ATI Vital Signs Skills (1)
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ATI Vital Signs Skills (1)
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ATI Vital Signs SkillsA nurse is preparing to record the difference between a client's systolic and diastolic blood
pressure. Which of the following terms defines this information when documenting?
A. Auscultatory Gap
B. Pulse Pressure
C. Orthostatic hypotension
D. Pulse Deficit - CORRECT ANSWER-B. Pulse Pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the client's
blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a
predictor of heart conditions, especially in older adults. For example, an elevated pulse pressure
usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or
atherosclerosis.
A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In
which of the following locations should the nurse position the stethoscope?
A. Over the right midclavicular line
B. Over the angle of Louis
C. Over the fifth intercostal space at the left midclavicular line
D. Over the suprasternal notch - CORRECT ANSWER-C. Over the fifth intercostal space at the
left midclavicular line
To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence just below
the suprasternal notch. The nurse should then slide their fingers down each side of the angle of
Louis to locate the second intercostal space. Next, the nurse should gently move their fingers
down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular
line. This is the PMI.
A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the
following actions should the nurse take to ensure an accurate reading?
A. Attach the disposable probe cover
B. Assess the external ear for redness
C. Pull the pinna back and upward gently
D. Replace the thermometer in its charger - CORRECT ANSWER-C. Pull the pinna back and
upward gently.
Gently pulling the pinna back and upward helps straighten the ear canal and provides optimal
access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential
for an accurate tympanic temperature measurement.
Not A - helps with bacteria/organism transmission, but not accuracy of tympanic measurement
Not B - tympanic thermometer is not recommended when a client's ear shows sign of infection
Not D - placing thermometer on charger does not help accuracy of tympanic measurement
A nurse is obtaining a client's vital signs. THe client has a new onset of a temperature of 39 C (102
F). Which of the following other vital signs should the nurse expect?
A. An elevated pulse rate
B. A decreased blood pressure
C. An elevated blood pressure
D. A decreased pulse rate - CORRECT ANSWER-A. A fever increases metabolic rate and
peripheral vasodilation, resulting in an increased pulse rate
, A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the
nurse take to measure the blood pressure accurately?
A. Obtain the reading in the early morning
B. Use a cuff of the appropriate size for the client
C. Assist the client to the bathroom to void
D. Apply the cuff loosely around the client's arm - CORRECT ANSWER-B. Use a cuff of the
appropriate size for the client
Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is too small
will result in a reading that is falsely high and using a cuff that is too big will record a false low. One
way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference
where the cuff will be wrapped. The bladder, which is inside the cuff, should surround 80% of the
arm circumference.
A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the
following factors will affect methods that are used? (select all)
A. The client who has a BMI of 35
B. The client who had nausea for 2 days
C. The client is reporting a "stuffy" nose
D. The client has been fasting for blood test
E. The client is taking digoxin for an irregular heart rate
F. The client had a mastectomy 2 years ago - CORRECT ANSWER-A, C, E, F
A. The client who has a BMI of 35 is correct. The client who has a BMI of 35 is overweight and has
a larger-than-average upper-arm circumference. Therefore, the nurse should use a large
blood-pressure cuff, instead of a regular-sized cuff, to ensure an accurate blood-pressure reading.
B. The client has had nausea for 2 days is incorrect. Nausea, while uncomfortable and possibly a
manifestation of gastrointestinal pathology, has no direct effect on the nurse assessing the client's
vital signs.
C. The client is reporting a "stuffy" nose is correct. The client who has nasal congestion might
resort to "mouth breathing," which would alter an oral temperature measurement. A respiration
assessment for a full 60 seconds should also be included.
D. The client has been fasting for blood tests is incorrect. The lack of food has no direct bearing on
checking the client's vital signs. However, recent ingestion of foods of extreme temperatures, hot
or cold, can affect the accuracy of an oral temperature measurement.
E. The client is taking digoxin for an irregular heart rate is correct. The presence of a
cardiovascular condition that warrants pharmacological digoxin therapy would require an
assessment of the client's apical pulse for a full 60 seconds.
F. The client had a mastectomy 2 years ago is correct. Lymphatic drainage might be altered in the
client's affected arm following a mastectomy. The application of pressure from the assessment of
blood pressure could result in a painful condition called lymphedema.
A nurse is measuring a client's temperature orally. Which of the following should the nurse take?
A. Place the probe in the posterior lingual pocket to the midline
B. Rest the probe on the lower lingual frenulum
C. Place the probe centrally on top of the client's tongue
D. Rest the probe under the tongue just beyond the client's teeth - CORRECT ANSWER-A. Rest
the probe on the lower lingual frenulum
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