The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?
An oral temperature of 100°F (37.8°C)
A respiratory rate of 30/min.
A radial pulse of 45 beats in 30 seconds.
A blood pressure of 114/74 mmHg.
The Correct Answer is C
Choice A rationale:
This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.
Choice B rationale:
This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.
Choice C rationale:
Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.
Choice D rationale:
Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.
Choice B rationale:
Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.
Choice C rationale:
Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.
Choice D rationale:
Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.
Correct Answer is D
Explanation
Choice A rationale:
Ears are located on the sides of the head, not between the cranial and thoracic cavities. The ears are lateral structures on the head.
Choice B rationale:
Elbow is a joint located in the upper limb, specifically in the arm. It is not between the cranial and thoracic cavities. The elbow is a joint that allows the forearm to bend.
Choice C rationale:
Knee is a joint in the lower limb, connecting the thigh bone to the shin bone. It is not located between the cranial and thoracic cavities. The knee joint allows for movements like bending and straightening of the leg.
Choice D rationale:
The nape of the neck refers to the back of the neck. It is the posterior part of the neck, located between the cranial (head) and thoracic (upper chest) cavities. The nape of the neck is a specific anatomical location.
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