Which assessment requires the nurse to assess the patient further?
40-year-old with a pulse of 88
18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike
50-year-old man with a BP of 112/60 mmHg on awakening in the morning
65-year-old with a respiratory rate of 10/min
The Correct Answer is D
A. 40-year-old with a pulse of 88. A resting pulse of 88 beats per minute is within the normal adult range (60–100 bpm) and does not require further assessment.
B. 18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike. An increased heart rate after exercise is a normal physiological response, and the heart rate should return to baseline after rest. No further assessment is needed unless tachycardia persists.
C. 50-year-old man with a BP of 112/60 mmHg on awakening in the morning. This blood pressure is within a normal range, especially in the early morning when BP is often lower. No additional assessment is required.
D. 65-year-old with a respiratory rate of 10/min. A normal respiratory rate for an adult is 12–20 breaths per minute. A respiratory rate of 10 is lower than normal and may indicate respiratory depression, which could be caused by medications such as opioids, neurological issues, or other conditions requiring further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.
Correct Answer is C
Explanation
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
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