ATI: Vital Signs Question and Answers
100% Pass
Which of the following is true regarding assessing a patient's pulse?
A. The human pulse is the palpable bounding of the blood flow in a peripheral artery.
B. The normal pulse range for a resting adult is 50 to 110 beats/min.
C. Three components that the nurse should include when documenting pulse (P) are the rate,
rhythm, and depth.
D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse
rate for 30 seconds and multiply by two. ✔✔A. When a peripheral artery can be compressed
against an underlying bone or muscle, the pulsation created by the ejection of blood from the heart
can be felt by palpating that site.
Which of the following temperatures is within the normal range for adults and is documented
correctly?
A. T = 98.6º F
B. T = 99.6º F (O)
C. T = 101.0º F (O) ✔✔B. Normal temperatures range from 96.8° F to 100.4° F. Appropriate
documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O),
tympanic (T), axillary (A), or rectal (R).
Which of the following accurately describes body temperature?
A. The difference between heat produced by and lost from the body
B. The total amount of heat produced by the body
C. The amount of heat produced by the body plus the amount of heat lost to the external
environment ✔✔A. Normal body temperature is the healthy balance between the amounts of heat
the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and
,sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and
evaporation.
The primary reason for assessing this patient's vital signs is to
A. establish a baseline when the patient reports no specific health-related problem.
B. determine the presence of any acute or chronic illness or disease process.
C. initiate the nursing process. ✔✔A. Vital signs are assessed for various reasons that include
determining the patient's response to medical and nursing therapy as well as identifying clinical
problems. However, the primary reason for such assessment at an initial visit of an apparently well
patient is to document baseline data. This information will be useful for comparison with vital-
sign data obtained at subsequent visits.
Will your assessment of respiration provide information about your patient's ability to intake
carbon dioxide and to expel oxygen?
A. Yes
B. No ✔✔B. Respiration is the mechanism a person uses to introduce oxygen into the body while
expelling carbon dioxide into the atmosphere.
Which of the following is true regarding assessing a patient's respiration?
A. It is best to inform the patient that you are assessing her respiration.
B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration.
C. Occurrence or periods of apnea in an older adult is a normal respiratory finding.
D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate. ✔✔B.
Appropriate documentation of respiration includes rate, rhythm (regular, irregular), and depth
(deep, normal, shallow).
Which of the following describes systolic pressure?
, A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation
phases of the heart
B. The pressure exerted by the blood during the heart's contraction phase
C. The pressure exerted by the blood during the heart's relaxation phase ✔✔B. Systolic pressure
describes the pressure exerted by the blood during the hearts contraction phase. The contraction of
the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when
ejection occurs is the systolic pressure.
You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult?
A. Yes.
B. No. ✔✔B. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults
may experience a rise as a result of decreased elasticity of the vessels; 140/90 is considered
hypertension while a systolic pressure of 90 mm Hg or less is considered hypotension. In any case,
166/88 exceeds the normal range.
Your patient's blood pressure exceeds the upper limit of the normal range for an adult, so you
measure it again.
Which of the following questions would be appropriate to ask your patient before you reassess her
blood pressure?
A. What is your usual blood-pressure reading?
B. Have you eaten anything within the last hour? C. Did you drink any tea, coffee, or soda within
the last half hour?
D. Are you currently experiencing any emotional stress such as fear or anxiety?
E. Have you smoked within the last 15 to 30 minutes? ✔✔A, C, D, E
How long would you wait before reassessing your patient's blood pressure on the same arm?
100% Pass
Which of the following is true regarding assessing a patient's pulse?
A. The human pulse is the palpable bounding of the blood flow in a peripheral artery.
B. The normal pulse range for a resting adult is 50 to 110 beats/min.
C. Three components that the nurse should include when documenting pulse (P) are the rate,
rhythm, and depth.
D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse
rate for 30 seconds and multiply by two. ✔✔A. When a peripheral artery can be compressed
against an underlying bone or muscle, the pulsation created by the ejection of blood from the heart
can be felt by palpating that site.
Which of the following temperatures is within the normal range for adults and is documented
correctly?
A. T = 98.6º F
B. T = 99.6º F (O)
C. T = 101.0º F (O) ✔✔B. Normal temperatures range from 96.8° F to 100.4° F. Appropriate
documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O),
tympanic (T), axillary (A), or rectal (R).
Which of the following accurately describes body temperature?
A. The difference between heat produced by and lost from the body
B. The total amount of heat produced by the body
C. The amount of heat produced by the body plus the amount of heat lost to the external
environment ✔✔A. Normal body temperature is the healthy balance between the amounts of heat
the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and
,sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and
evaporation.
The primary reason for assessing this patient's vital signs is to
A. establish a baseline when the patient reports no specific health-related problem.
B. determine the presence of any acute or chronic illness or disease process.
C. initiate the nursing process. ✔✔A. Vital signs are assessed for various reasons that include
determining the patient's response to medical and nursing therapy as well as identifying clinical
problems. However, the primary reason for such assessment at an initial visit of an apparently well
patient is to document baseline data. This information will be useful for comparison with vital-
sign data obtained at subsequent visits.
Will your assessment of respiration provide information about your patient's ability to intake
carbon dioxide and to expel oxygen?
A. Yes
B. No ✔✔B. Respiration is the mechanism a person uses to introduce oxygen into the body while
expelling carbon dioxide into the atmosphere.
Which of the following is true regarding assessing a patient's respiration?
A. It is best to inform the patient that you are assessing her respiration.
B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration.
C. Occurrence or periods of apnea in an older adult is a normal respiratory finding.
D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate. ✔✔B.
Appropriate documentation of respiration includes rate, rhythm (regular, irregular), and depth
(deep, normal, shallow).
Which of the following describes systolic pressure?
, A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation
phases of the heart
B. The pressure exerted by the blood during the heart's contraction phase
C. The pressure exerted by the blood during the heart's relaxation phase ✔✔B. Systolic pressure
describes the pressure exerted by the blood during the hearts contraction phase. The contraction of
the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when
ejection occurs is the systolic pressure.
You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult?
A. Yes.
B. No. ✔✔B. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults
may experience a rise as a result of decreased elasticity of the vessels; 140/90 is considered
hypertension while a systolic pressure of 90 mm Hg or less is considered hypotension. In any case,
166/88 exceeds the normal range.
Your patient's blood pressure exceeds the upper limit of the normal range for an adult, so you
measure it again.
Which of the following questions would be appropriate to ask your patient before you reassess her
blood pressure?
A. What is your usual blood-pressure reading?
B. Have you eaten anything within the last hour? C. Did you drink any tea, coffee, or soda within
the last half hour?
D. Are you currently experiencing any emotional stress such as fear or anxiety?
E. Have you smoked within the last 15 to 30 minutes? ✔✔A, C, D, E
How long would you wait before reassessing your patient's blood pressure on the same arm?
