A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?
Auscultation
Percussion
Palpation
Inspection
The Correct Answer is C
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Axillary. The axillary method is less accurate because it measures surface temperature, which can be influenced by environmental factors and is typically lower than core temperature.
B. Rectal. The rectal route provides the most accurate core temperature measurement because it closely reflects internal body temperature and is less affected by external conditions. It is commonly used in critically ill patients and infants when precise measurements are needed.
C. Forehead. Forehead (temporal artery) thermometers provide a non-invasive method of measuring temperature but can be less accurate due to external factors like sweating or ambient temperature changes.
D. Oral. Oral temperature is commonly used and provides a good estimate of core temperature, but factors like recent eating, drinking, or mouth breathing can affect accuracy. Rectal temperature remains the most precise method.
Correct Answer is C
Explanation
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
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