Your 95-year-old client's vital signs are as follows: oral T 98.6 F: P (radial) 84 with irregularity: R 18. normal depth, & regular: BP (left arm, sitting) 140/86. Which nursing assessment(s) would be done to obtain more data at this time?
Positional BP readings
Carotid pulse and temperature
Full respiratory system assessment
Apical pulse for one minute
The Correct Answer is D
A. Positional BP readings. While orthostatic blood pressure readings can assess for postural hypotension, there is no indication in the current vitals that the client is experiencing symptoms such as dizziness or syncope.
B. Carotid pulse and temperature. The client’s temperature is already documented as normal, and the carotid pulse is not needed when an irregular radial pulse has been noted. The apical pulse is the preferred method to assess for irregularities.
C. Full respiratory system assessment. The respiratory rate is within the normal range, with regular rhythm and normal depth, so a full respiratory assessment is not the immediate priority.
D. Apical pulse for one minute. An irregular radial pulse suggests the possibility of an arrhythmia. The apical pulse provides a more accurate assessment of heart rhythm and rate, ensuring a complete evaluation of the irregularity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.
B. 100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.
C. 200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.
D. 200/100/92. The correct way to document blood pressure when Korotkoff sounds muffle before disappearing is to include all three values: the systolic pressure (Phase I), the point of muffling (Phase IV), and the diastolic pressure (Phase V). This ensures a complete and accurate blood pressure recording.
Correct Answer is B
Explanation
A. Positioning the bell very lightly over the patient's sternum. The bell is best for low-pitched sounds like murmurs, but heartbeats (especially S1 and S2) are better heard with the diaphragm over the apex of the heart, not the sternum.
B. Placing the diaphragm firmly against the patient's skin. The diaphragm is designed to pick up high-pitched sounds like the normal S1 and S2 heart sounds. Pressing firmly helps eliminate external noise and improves sound clarity.
C. Utilizing a stethoscope with the longest possible tubing. Longer tubing can reduce sound transmission quality. Shorter tubing (about 14-18 inches) provides clearer sound.
D. Making sure that the earpieces fit loosely in the nurse's ear canals. Earpieces should fit snugly, not loosely, to ensure optimal sound conduction and block external noise.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.