A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?

Temperature

Pulse

Respiratory rate

Blood pressure

Answer and Explanation

The Correct Answer is C

In cases where a client presents with acute symptoms, the nurse must use clinical judgment to determine whether vital sign assessment requires nursing-level evaluation, particularly for parameters that require observation, interpretation, or correlation with clinical symptoms.

Rationale for correct answer:

C. Respiratory rate is the most sensitive indicator of deterioration and must often be assessed by a nurse, especially in clients with dyspnea or altered mental status.

Rationale for incorrect answers:

A. Temperature: Taking temperature is a simple, objective task that is appropriate to delegate to trained personnel.

B. Pulse can generally be delegated, especially when using automated equipment.

D. Blood Pressure is usually safe to delegate to trained personnel. While the nurse should evaluate the results, the act of measuring BP (especially with an automated device) does not require advanced assessment skills unless there's an abnormality.

Take-home points:

Respiratory rate is often under-assessed but is critical for identifying early clinical deterioration, especially in clients with dyspnea or confusion.
Delegation decisions must always factor in client stability, the complexity of the task, and the skill level required to interpret findings.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Postoperative patients, especially those with heart failure, are at increased risk for orthostatic hypotension due to bedrest, anesthetic effects, and volume shifts. Orthostatic intolerance may manifest as dizziness, nausea, or fainting when the client is moved from lying to sitting or standing.

Rationale for correct answers:

A. Lower the head of the bed and return the patient to the supine position: This is the first and most important safety step to prevent fainting or falls. Returning to a supine position helps restore cerebral perfusion, relieving dizziness.

B. Obtain vital signs: Vital signs (especially blood pressure and heart rate) should be obtained to assess for orthostatic hypotension or other hemodynamic instability.

D. Allow the patient to rest for 20 to 30 minutes: After returning to a safe position, resting allows stabilization of blood pressure and heart rate. Many patients tolerate activity better after a brief rest period.

E. Raise the head of the bed again and obtain blood pressure readings: Gradually raising the head of the bed and monitoring orthostatic BPs is part of safely assessing tolerance to positional changes.

Rationale for incorrect answer:

C. Encourage the patient to try to sit on the side of the bed and then stand: Encouraging further movement while the patient is symptomatic is unsafe. Doing so may worsen symptoms and risk falls or cardiovascular collapse.

Take-home points:

Immediate safety actions (return to supine, assess vitals) are essential when a patient becomes dizzy with movement.
Orthostatic BP monitoring and gradual progression to activity can help prevent falls and guide safe ambulation.

A. 1 B. 2 C. 3 D. 4 E. 5

Correct Answer is A

Explanation

The Point of Maximal Impulse (PMI), also referred to as the apical impulse, is the location on the chest wall where the heartbeat is most strongly felt or heard. It corresponds to the apex of the heart, typically located at the 5th intercostal space, midclavicular line in adults

Rationale for correct answers:

E. Near apex: This point corresponds to the 5th intercostal space at the midclavicular line, where the apex of the heart contacts the chest wall. It is the most accurate site for auscultating the apical pulse and evaluating left ventricular function.

Rationale for incorrect answers:

A. To the right of the aorta. This is in the right upper sternal border, typically used to auscultate the aortic valve area. It is not associated with the PMI or apex of the heart.

B. At left atrium: This is positioned more posteriorly in the chest and not palpable or auscultated directly from the anterior chest wall.

C. Placed slightly below 2: Still in the left parasternal area, likely over the pulmonic or tricuspid area, but not the apex.

D. Placed slightly below 3: This is near the left lower sternal border, where tricuspid sounds may be heard, but it's still not the apex.

F. At xiphoid process: This is the epigastric area, well below the heart’s apex, and is not used to assess apical pulse or PMI.

Take-home points:

The PMI is best auscultated at the 5th intercostal space, midclavicular line, which corresponds to point 5 in the diagram.
Accurate location of the PMI is essential in assessing left ventricular function and detecting cardiac enlargement or displacement.

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A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","E"]

Explanation

Which number marks the location where the nurse would auscultate the point of maximal impulse (PMI)?

Correct Answer is A

Explanation

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