The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

count the radial pulse for two minutes."

put my fingers on the "pinky" finger side of the wrist."

use my thumb to count the pulse."

count the pulse for 30 seconds and multiply the number by two

Answer and Explanation

The Correct Answer is D

D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.

A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).

B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.

C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.

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Correct Answer is A

Explanation

A. The pulmonic valve is best auscultated at the second intercostal space (ICS) on the left sternal border. This is where the area corresponding to the pulmonic valve is most accurately heard due to the anatomical positioning of the heart.

B. This area does not correspond to any valvular area.

C. This location corresponds to the aortic valve, not the pulmonic valve. The aortic valve is best auscultated at the second ICS, right sternal border.

D. This location corresponds to the tricuspid valve, not the pulmonic valve. The tricuspid valve is best auscultated at the fourth or fifth ICS along the left sternal border.

A. Massage the client's bony areas every hour B. Encourage the client to deep breathe and cough every hour C. Provide tube feedings every two hours D. Change the client's position every two hours

Correct Answer is B

Explanation

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

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The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

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Naxlex Comprehensive Predictor Exams

The nurse is completing a cardiac assessment on a client. The pulmonic valve would best be assessed by auscultating at the:

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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