A nurse is assessing a sedated client whose respiratory rate has fallen below 10 respirations per minute.
The nurse identifies this condition as what?
Tachypnea.
Apnea.
Bradypnea.
Eupnea.
The Correct Answer is A
Choice A rationale:
Diastolic pressure represents the pressure in the arteries when the heart is at rest between contractions. It specifically measures the force of blood against the arterial walls when both the atria and ventricles are relaxed, allowing the heart to fill with blood. Diastolic pressure is the bottom number in a blood pressure reading (e.g., 120/80 mmHg), indicating the pressure in the arteries during the heart's resting phase. Elevated diastolic pressure is an important indicator of increased risk for cardiovascular diseases, such as hypertension.
Choice B rationale:
This statement describes systolic blood pressure, which measures the pressure in the arteries when the heart's ventricles contract and pump blood into the circulation. Systolic pressure is the top number in a blood pressure reading (e.g., 120/80 mmHg) and represents the highest pressure reached in the arteries during a cardiac cycle.
Choice C rationale:
This description is not accurate for either diastolic or systolic pressure. Both atria and ventricles do not contract simultaneously; they follow a specific sequence to ensure effective pumping of blood through the heart.
Choice D rationale:
This statement is incorrect as it does not align with the definitions of diastolic or systolic blood pressure. Diastolic pressure specifically measures the pressure in the arteries during the heart's resting phase, not when the ventricles relax. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.
Choice B rationale:
Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.
Choice C rationale:
Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.
Choice D rationale:
Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.
Correct Answer is ["D"]
Explanation
The correct answer is Choice D. Speak with the AP before leaving the shift about the appropriate protocol.
Choice A rationale: Giving the AP the appropriate PPE is not the best action for the nurse to take. While this might prevent the AP from spreading the infection to other clients or themselves, it does not address the root cause of the problem, which is the AP’s lack of knowledge or compliance with the infection control policies. The nurse should educate the AP about the importance of wearing PPE and the consequences of not doing so. Giving the AP the appropriate PPE might also imply that the nurse condones the AP’s behavior, which could undermine the nurse’s authority and credibility.
Choice B rationale: Notifying the charge nurse about the AP’s lack of PPE is not the best action for the nurse to take. While this might alert the charge nurse to the issue and prompt corrective action, it does not demonstrate the nurse’s leadership and communication skills. The nurse should first attempt to resolve the issue directly with the AP, as this shows respect and professionalism. Notifying the charge nurse might also create a sense of distrust and resentment between the nurse and the AP, which could affect their working relationship and teamwork.
Choice C rationale: Volunteering to provide an in-service about infection control is not the best action for the nurse to take. While this might be a helpful and proactive way to educate the staff about the infection control policies and procedures, it does not address the immediate issue of the AP’s lack of PPE. The nurse should first speak with the AP and ensure that they understand and follow the contact precautions for the client. Volunteering to provide an in-service might also be seen as overstepping the nurse’s role and scope of practice, as this is usually the responsibility of the infection control nurse or the staff development coordinator.
Choice D rationale: Speaking with the AP before leaving the shift about the appropriate protocol is the best action for the nurse to take. This shows that the nurse is concerned about the AP’s safety and the client’s well-being, as well as the infection control standards. The nurse should explain to the AP why they need to wear PPE when entering the room of a client who is under contact precautions, and what are the risks of not doing so. The nurse should also provide the AP with feedback and reinforcement, and document the incident and the intervention. Speaking with the AP before leaving the shift also ensures that the issue is addressed in a timely and respectful manner, and that the nurse and the AP have a clear and consistent understanding of the expectations and the outcomes.
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