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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bradycardia is defined as a heart rate lower than 60 beats per minute. Therefore, 62 beats per minute is not bradycardic.
B. 59 beats per minute would be considered bradycardic, as it is below 60.
C. 64 beats per minute is within normal limits.
D. 60 beats per minute is on the threshold of bradycardia but typically is still within normal limits for some individuals.
Correct Answer is D
Explanation
A. A stronger pulse is typically associated with increased stroke volume or cardiac output.
B. Bradycardia is not directly related to a reduced stroke volume; pulse rate may not necessarily decrease.
C. An irregular pulse is more associated with arrhythmias or other cardiac conditions, not a reduction in stroke volume.
D. A weaker pulse is expected with a reduced stroke volume, as less blood is being pumped with each heartbeat, leading to a diminished pulse.
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