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 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.
Correct Answer is B
Explanation
Choice A rationale:
Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.
Choice B rationale:
Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.
Choice C rationale:
Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.
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