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 dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.

D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.

A. a drop of 15 to 20 mm Hg from baseline when changing position. B. dizziness upon rising to a standing position. C. blurred vision. D. syncope.

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

Explanation

A. A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B. Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C. Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D. Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

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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 D

Explanation

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

Explanation

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