A nurse explains to a client's family that the client's respirations are faster and deeper than normal because of what?

The client is expelling too much carbon dioxide.

The client's blood oxygen level indicates hypoxemia.

The client has developed an inflammation of the phrenic nerve.

The client is using his intercostal muscles to breathe.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.

Choice B rationale:

Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.

Choice C rationale:

Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.

Choice D rationale:

Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.

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Correct Answer is A

Explanation

Choice A rationale:

An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.

Choice B rationale:

A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.

Choice C rationale:

A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.

Choice D rationale:

A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.

A. An oral temperature of 100°F (37.8°C) B. A respiratory rate of 30/min. C. A radial pulse of 45 beats in 30 seconds. D. A blood pressure of 114/74 mmHg.

Correct Answer is C

Explanation

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .

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A nurse explains to a client's family that the client's respirations are faster and deeper than normal because of what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

Correct Answer is A

Explanation

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

Correct Answer is C

Explanation

To accurately take a client's blood pressure, which action by the nurse is most important?

Macroglossia means:

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