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 D

Explanation

A. The date of previous diagnostic tests may be important, but it is secondary to immediate safety concerns like allergies.
B. Information about the patient's living situation can be useful for discharge planning but is not the most urgent piece of information.
C. Previous treatment for illnesses is important but does not supersede immediate health threats like allergies.
D. Knowing any allergies to medications is critical to avoid potentially harmful reactions. This is a priority when beginning care, as it informs medication administration and treatment options.

A. allows loss of body heat. B. an be reshaped more quickly. C. is wet and needs to be dried. D. has large fontanels.

Correct Answer is A

Explanation

A. The newborn’s head is a major source of heat loss due to the large surface area and insufficient
insulation. Covering the head helps maintain body temperature.
B. While the head can be reshaped, the primary reason for covering it is to prevent heat loss, not reshaping.
C. The head is not necessarily wet and doesn't require drying in all cases, making this less relevant.
D. Although the head has large fontanels, this is not the reason it is covered with a cap; preventing heat loss is the priority.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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