A nurse is assessing peripheral pulses on a client and is aware that which action is a safety issue when assessing the client's peripheral pulses?

Counting a regular pulse for 30 seconds and doubling the number to obtain the rate.

Palpates the femoral artery in the groin of the client.

Palpates both carotid pulses at the same time.

Palpates the radial artery on the thumb side of the wrist.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish remover or hair spray should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

Correct Answer is ["D"]

Explanation

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

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A nurse is assessing peripheral pulses on a client and is aware that which action is a safety issue when assessing the client's peripheral pulses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

Correct Answer is ["D"]

Explanation

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