A nurse is assessing peripheral pulses on a client and is aware that which action is a safety issue when assessing the client's peripheral pulses?
Counting a regular pulse for 30 seconds and doubling the number to obtain the rate.
Palpates the femoral artery in the groin of the client.
Palpates both carotid pulses at the same time.
Palpates the radial artery on the thumb side of the wrist.
The Correct Answer is A
Choice A rationale:
The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.
Choice B rationale:
This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.
Choice C rationale:
This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.
Choice D rationale:
This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Confine the fire by closing doors and windows. While confining the fire is important, the nurse's first priority should be ensuring the safety of the client. Closing doors and windows may help prevent the fire from spreading, but it does not address the immediate danger to the client.
Choice B rationale:
Activate the fire alarm system. Activating the fire alarm is a crucial step to alert other staff members, patients, and visitors about the fire. However, it is not the first action the nurse should take. Ensuring the safety of the client should be the top priority.
Choice C rationale:
Extinguish the fire if possible. Attempting to extinguish the fire can be dangerous for the nurse and may waste precious time. The nurse's safety and the client's safety should be the primary concern. Trying to put out the fire before ensuring the client's safety is not the best course of action.
Choice D rationale:
Rescue the client from immediate danger. This is the correct answer because the nurse's first priority in a fire emergency is to ensure the safety of the client. Rescuing the client from immediate danger should be done before any other actions are taken. The nurse should assess the situation, help the client to safety, and then notify others about the fire and activate the alarm system.
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.
Choice B rationale:
Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.
Choice C rationale:
Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.
Choice D rationale:
Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.
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