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ATI RN · ATI Fundamentals · Vital Signs Assessment Quizlet

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A nurse is assessing a client's body temperature. Which route provides the most accurate measurement of core body temperature?

A. Oral

B. Axillary

C. Temporal

D. Rectal

Expert Explanatory Rationale

Correct Answer: Rectal

Question 2 of 5

Which step of the nursing process includes data collection by health history, physical examination, and interview?

A. Planning.

B. Diagnosis.

C. Evaluation.

D. Assessment.

Expert Explanatory Rationale

Correct Answer: Assessment.

Question 3 of 5

During a cardiovascular assessment, the nurse auscultates a murmur. What is the next step in the assessment?

A. Assess for signs of heart failure.

B. Document the murmur.

C. Auscultate for any other abnormal heart sounds.

D. Order an electrocardiogram (ECG).

Expert Explanatory Rationale

Correct Answer: Auscultate for any other abnormal heart sounds.

Question 4 of 5

Cyanosis is ...

A. Pale, ashen, blue or grayish skin

B. Indicates a lack of oxygen

C. Can be found around the mouth

D. All of the above

Expert Explanatory Rationale

Correct Answer: All of the above

Question 5 of 5

When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement?

A. MAP is the pressure of the arterial pulse.

B. MAP reflects the stroke volume of the heart.

C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.

D. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Expert Explanatory Rationale

Correct Answer: MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.

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