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 ["473"]
Explanation
The correct answer is choice: 473.
To convert 4 ounces to milliliters (mL), the following steps can be taken:
Understand the Conversion Factor: 1 fluid ounce (oz) is approximately 29.57 mL. Therefore, 4 oz can be converted to mL using the following calculation: 4 × 29.57 = 118.28
4oz × 29.57mL/oz = 118.28mL.
Convert Cups to Ounces: 1 cup is equal to 8 fluid ounces.
Therefore, 1 cup is 8 × 29.57= 236.56
8oz × 29.57mL/oz = 236.56mL.
So, 1 cup is equal to 236.56 mL. The correct answer is 473 mL (2 cups)
Correct Answer is ["2"]
Explanation
Diazepam is prescribed in a 10 mg dose, and the concentration of diazepam in the injection is 5 mg per mL. By dividing the prescribed dose (10 mg) by the concentration of the drug in the injection (5 mg/mL), the result is 2 mL. This is the correct administration dose.
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