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 A

Explanation

A. Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B. Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C. Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D. Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.

A. pulse deficit B. diastolic C. auscultatory gap D. widened pulse pressure

Correct Answer is C

Explanation

A. Pulse deficit refers to the difference between the apical and radial pulse, not a silence between sounds during blood pressure measurement.
B. Diastolic refers to the phase of the blood pressure cycle when the heart is at rest, not to a silent period.
C. An auscultatory gap is a period of silence between the systolic and diastolic sounds heard when taking blood pressure. It can be indicative of arterial stiffness or other vascular issues.
D. Widened pulse pressure refers to the difference between systolic and diastolic pressures, not a silence during auscultation.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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