During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Wait until the end of the physical assessment to reassess the radial pulse.

Reassess the client's pedal pulse on the other foot.

Assess the client's 51 and 52 sounds for regularity.

Assess the client's apical pulse for a full minute.

Answer and Explanation

Correct Answer : A,D

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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Correct Answer is C

Explanation

Rationale:
A. Fever: While fever might be a symptom of infection, it is not specific to inner ear infections.

B. Headache: This can be a symptom associated with inner ear infections, but vertigo is a more specific concern.

C. Vertigo: Inner ear infections often cause vertigo (dizziness or spinning sensations), so interventions for managing vertigo are crucial.

D. Rhinorrhea: This symptom is more commonly associated with upper respiratory infections rather than inner ear infections.

A. II B. III C. I D. X

Correct Answer is C

Explanation

A. II: A grade II murmur is generally faint but still audible with the stethoscope in place.

B. III: A grade III murmur is moderately loud and can be heard with the stethoscope without applying extra pressure.

C. I: A grade I murmur is very faint and might be heard only with careful listening and with the stethoscope placed carefully.

D. X: There is no grade X murmur in the standard grading scale for heart murmurs.

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During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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