A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

Document information directly from a textbook.

Copy previous nursing assessment.

Document their findings.

Seek clarification from a more experienced nurse.

Answer and Explanation

The Correct Answer is D

A. Documenting information directly from a textbook is incorrect because textbooks provide general guidelines, not client-specific data. The student's assessment findings should be based on the actual client’s condition.
B. Copying a previous nursing assessment is incorrect and unethical. Each assessment must be conducted independently to ensure accurate and up-to-date client care.
C. Documenting findings without confidence in their accuracy can lead to errors in client care. If the student is uncertain, verification is necessary before documentation.
D. Seeking clarification from a more experienced nurse is correct. If a student nurse is unsure of their assessment findings, they should ask a preceptor or experienced nurse for guidance to ensure accuracy and safe client care.

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Correct Answer is A

Explanation

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

A. Air being diverted from the trachea to the bronchi B. Air passing through constricted passageways C. Air increasing in turbulence in a wide passage D. Air leaking from the alveoli into the pleural space

Correct Answer is B

Explanation

A. Air being diverted from the trachea to the bronchi does not explain the cause of a wheeze. This is a normal part of airflow distribution.
B. Air passing through constricted passageways is correct. A wheeze is a high-pitched, musical sound that occurs when air flows through narrowed or obstructed airways, as seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
C. Air increasing in turbulence in a wide passage is incorrect. Wheezing occurs due to airway narrowing, not widening.
D. Air leaking from the alveoli into the pleural space describes pneumothorax, which presents with absent breath sounds rather than wheezing.

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A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Correct Answer is A

Explanation

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

Correct Answer is B

Explanation

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A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?