A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

listens to the apical pulse for 1 full minute.

records the findings on the graphic sheet.

takes the pulse for 30 seconds on the other wrist.

takes the pulse for 1 full minute on the other wrist.

Answer and Explanation

The Correct Answer is A

A.   Listening to the apical pulse for one full minute provides a more accurate reading of the heart rate and rhythm, especially when the radial pulse is irregular.
B.   Recording the findings on the graphic sheet is necessary, but it doesn’t address the irregularity of the pulse.
C.   Taking the pulse on the other wrist does not provide the necessary information about the apical pulse.
D.   Taking the pulse for one full minute on the other wrist is not necessary unless the pulse is absent on the first wrist.

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Correct Answer is C

Explanation

A. Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B. A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C. A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D. Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.

A. "When I shine a light into the patient's eyes, the pupils should constrict." B. "It is normal for the pupils to react sluggishly to light." C. "When I shine a light into the patient's eyes, the pupils should dilate D. "Pupil checks should be performed with the room lights on."

Correct Answer is A

Explanation

A. The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B. While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C. Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D. Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.

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