A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
Carotid
Popliteal
Femoral
Brachial
The Correct Answer is A
Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.
Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.
Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.
Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.
Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.
Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.
Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.
Correct Answer is B
Explanation
Choice A reason: Going to bed and waking up at the same times each day is a recommended practice for good sleep hygiene. It helps to regulate the body's internal clock and can improve sleep quality.
Choice B reason: Watching television until falling asleep is not recommended for healthful sleep habits. The light emitted from screens can interfere with the body's production of melatonin, the hormone that regulates sleep, and can make it more difficult to fall asleep.
Choice C reason: Avoiding naps, especially in the afternoon or evening, can help ensure that a person is sufficiently tired at bedtime, which can improve the ability to fall asleep and maintain sleep throughout the night.
Choice D reason: Having a small snack and taking a bath before bed can be part of a relaxing bedtime routine. A light snack can prevent hunger from disrupting sleep, and a warm bath can help to relax the body and signal that it's time to wind down.
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