A nurse is checking a patient’s pulse and determines that the rate is irregular. How long should the nurse measure the pulse?
15 seconds and multiply by 4.
30 seconds and multiply by 2.
60 seconds.
45 seconds and multiply by 2.
The Correct Answer is C
Choice A reason: Measuring pulse for 15 seconds and multiplying by 4 assumes a regular rhythm, which is inaccurate for an irregular pulse. Irregular rhythms, such as atrial fibrillation, require longer measurement to capture variability in heartbeats, ensuring an accurate rate. This method risks over- or underestimating the true pulse rate.
Choice B reason: Counting for 30 seconds and multiplying by 2 is insufficient for an irregular pulse, as it may miss variations in heart rate, common in arrhythmias. Accurate assessment of irregular rhythms, like premature ventricular contractions, demands a full minute to account for fluctuations, making this method less reliable.
Choice C reason: Measuring the pulse for 60 seconds is the standard for irregular rhythms, as it captures the full range of heart rate variability. Conditions like atrial fibrillation cause inconsistent beats, and a full minute ensures accuracy in counting, aligning with clinical guidelines for assessing cardiovascular status in such cases.
Choice D reason: Counting for 45 seconds and multiplying by 2 is not a standard practice for irregular pulses. It fails to account for the full variability in heart rate, potentially skewing results in conditions like arrhythmias. A 60-second count is necessary for precision in irregular rhythm assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Medication reconciliation involves compiling a complete, accurate list of current medications, including prescriptions, supplements, herbals, and OTC drugs, to ensure safe transitions across care settings. This prevents errors like omissions or duplications, critical for patient safety, guiding accurate prescribing and reducing adverse drug events in clinical practice.
Choice B reason: Listing medications prescribed at discharge is part of discharge planning, not full medication reconciliation, which includes all current medications across settings. This narrow definition risks missing ongoing therapies, leading to errors like discontinued drugs, compromising safety and continuity of care during transitions in healthcare settings.
Choice C reason: Listing medication allergies is part of allergy documentation, not medication reconciliation, which focuses on current medications. Confusing these risks overlooking active prescriptions, leading to potential drug errors or interactions. Reconciliation ensures a comprehensive medication profile, critical for safe prescribing and patient care across healthcare transitions.
Choice D reason: Obtaining medication interactions is a pharmacist’s analysis, not medication reconciliation, which compiles a current medication list. Assuming this misaligns with reconciliation’s purpose, risking incomplete profiles and errors like missed doses. Reconciliation ensures accurate medication records, essential for preventing adverse events and supporting safe care transitions.
Correct Answer is B
Explanation
Choice A reason: Joint deformity is an unexpected musculoskeletal finding, indicating conditions like arthritis or trauma, requiring intervention. Symmetrical movement is normal. Assuming deformity is expected risks neglecting serious issues, delaying treatments like physical therapy or surgery, critical for restoring function and preventing disability in affected patients.
Choice B reason: Symmetrical degrees of movement are expected in musculoskeletal assessments, indicating normal joint function and muscle strength. Asymmetry, deformity, or limited movement are abnormal. Recognizing this ensures focus on true abnormalities, guiding accurate diagnosis and interventions for musculoskeletal issues, critical for maintaining mobility and function in patients.
Choice C reason: Limited ability to complete maneuvers is an unexpected finding, suggesting joint stiffness, pain, or weakness, possibly from arthritis or injury. Symmetrical movement is normal. Assuming this is expected risks missing treatable conditions, delaying interventions like therapy or medication, critical for improving musculoskeletal function and patient quality of life.
Choice D reason: Differences in movement between right and left sides are unexpected, indicating asymmetry from conditions like stroke or injury. Symmetrical movement is normal. Assuming asymmetry is expected risks overlooking neurological or musculoskeletal issues, delaying diagnosis and rehabilitation, critical for restoring balanced function in patients with movement disparities.
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