A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates

Decreased plasma volume.

Problems with the heart's electrical conduction system.

Shock.

A blockage of blood flow.

Answer and Explanation

The Correct Answer is D

A.   Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B.   Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C.   Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.

D.   A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.

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Correct Answer is B

Explanation

A: Hypoglycemia does not directly correlate with a lower heart rate.

B: A heart rate of 56/min may indicate bradycardia, which can lead to symptoms like dizziness due to decreased cardiac output and subsequently reduced cerebral perfusion.
C: A fever would typically increase the heart rate, not decrease it.

D: Cigarette smoking is more commonly associated with an increased heart rate due to stimulants like nicotine.

A. Check the blood pressure with the client in a supine position. B. Place the client in a sitting position. C. Determine the client's blood pressure 1 min after each position change. D. Assist the client into a standing position.

Correct Answer is A

Explanation

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

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