A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

listens to the apical pulse for 1 full minute.

records the findings on the graphic sheet.

takes the pulse for 30 seconds on the other wrist.

takes the pulse for 1 full minute on the other wrist.

Answer and Explanation

The Correct Answer is A

A.   Listening to the apical pulse for one full minute provides a more accurate reading of the heart rate and rhythm, especially when the radial pulse is irregular.
B.   Recording the findings on the graphic sheet is necessary, but it doesn’t address the irregularity of the pulse.
C.   Taking the pulse on the other wrist does not provide the necessary information about the apical pulse.
D.   Taking the pulse for one full minute on the other wrist is not necessary unless the pulse is absent on the first wrist.

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Correct Answer is ["A","C"]

Explanation

A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

A. place the arm so that the brachial artery is at waist level. B. chat with the patient to reduce any anxiety in the patient. C. request that the patient put feet flat on the floor. D. position the patient so that the arm is level with the shoulder.

Correct Answer is C

Explanation

A. The brachial artery should be at heart level, not waist level, to ensure accurate blood pressure readings.
B. While chatting with the patient may help reduce anxiety, it is not directly related to positioning for accurate blood pressure measurement.
C. Having the patient place their feet flat on the floor ensures proper positioning and helps prevent any interference with blood pressure readings.
D. The arm should be at heart level, not at the shoulder, for accurate readings.

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A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

Correct Answer is ["A","C"]

Explanation

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Correct Answer is C

Explanation

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