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.
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.
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 B
Explanation
Choice A rationale:
Gastro- refers to the stomach. This prefix is commonly used in medical terminology to indicate conditions related to the stomach or the gastrointestinal system.
Choice B rationale:
Nephro- is the correct medical term for kidney. The prefix nephro- is used to indicate conditions related to the kidney, such as nephritis (inflammation of the kidney)
Choice C rationale:
Oto- refers to the ear. This prefix is commonly used in medical terms related to the ear and hearing, such as otitis (inflammation of the ear)
Choice D rationale:
Uro- refers to the urinary tract. While it is related to the kidneys in the context of the urinary system, it is not the specific term for kidney. Uro- is used in words like urology (the branch of medicine that deals with the urinary system and male reproductive system)
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