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 D
Explanation
Choice A reason: A blood pressure of 90/80 mmHg is below normal, indicating hypotension, especially with a low systolic value. Normal adult blood pressure, per guidelines, is around 120/80 mmHg. Low readings may suggest dehydration or cardiovascular issues, requiring evaluation, making this choice incorrect.
Choice B reason: A reading of 95/60 mmHg is hypotensive, with both systolic and diastolic values below normal ranges. Normal blood pressure is approximately 120/80 mmHg, per American Heart Association guidelines. Such low readings may indicate shock or autonomic dysfunction, rendering this choice incorrect.
Choice C reason: A blood pressure of 180/60 mmHg is abnormal, with elevated systolic pressure indicating hypertension and a low diastolic value suggesting possible aortic regurgitation. Normal blood pressure is 120/80 mmHg. This reading requires urgent assessment, making it an incorrect choice for normal adult values.
Choice D reason: A blood pressure of 120/80 mmHg is considered normal for adults, per current guidelines like those from the American Heart Association. It reflects balanced systolic and diastolic pressures, indicating healthy cardiovascular function without signs of hypertension or hypotension, making it the correct choice.
Correct Answer is C
Explanation
Choice A reason: Full range of motion against gravity only corresponds to a 3/5 muscle strength rating, indicating the muscle can move the joint against gravity but not additional resistance. This is weaker than 4/5, which includes some resistance, making this choice incorrect for the described strength level.
Choice B reason: Visible muscle contraction without joint movement indicates a 1/5 rating, reflecting minimal strength, often seen in severe neurological or muscular disorders. This is far below a 4/5 rating, which requires full range of motion and resistance, making this choice irrelevant to the question.
Choice C reason: A 4/5 muscle strength rating indicates full range of motion against gravity with some resistance, but not maximal. This reflects good muscle function, slightly below normal, often due to minor injury or fatigue. It aligns with standard muscle strength scales, making it the correct choice.
Choice D reason: Full range of motion against gravity with full resistance corresponds to a 5/5 rating, indicating normal muscle strength. This is stronger than 4/5, which involves only some resistance, reflecting a slight deficit. This choice does not match the described strength level.
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