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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B. Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C. Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D. Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.
Correct Answer is ["A","B","D"]
Explanation
A persistent cough can indicate lung cancer or other types of cancer affecting the respiratory system, making it a warning sign that should be noted.
B. Difficulty swallowing, or dysphagia, can be indicative of cancer in the esophagus, throat, or mouth, and should raise concern when observed.
C. Changes in pulse rate are typically not direct indicators of cancer; however, they could result from underlying conditions related to cancer treatment or progression.
D. An obvious change in a mole, especially in size, shape, or color, is a well-known warning sign of skin cancer, specifically melanoma.
E. Vesicular breath sounds are normal breath sounds, not linked to cancer.
F. Hyperactive bowel sounds could indicate a gastrointestinal issue but are not specific to cancer.
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