During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Wait until the end of the physical assessment to reassess the radial pulse.

Reassess the client's pedal pulse on the other foot.

Assess the client's 51 and 52 sounds for regularity.

Assess the client's apical pulse for a full minute.

Answer and Explanation

Correct Answer : A,D

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

A. Tuning fork B. Stethoscope C. Ophthalmoscope D. Tongue depressor

Correct Answer is A

Explanation

A. Tuning fork: A tuning fork is used in auditory assessments, such as hearing tests, to evaluate hearing loss and bone conduction.

B. Stethoscope: While a stethoscope is essential for auscultation of heart and lung sounds, it is not used for examining the ears.

C. Ophthalmoscope: An ophthalmoscope is used for examining the eyes, not the ears.

D. Tongue depressor: A tongue depressor is used for examining the mouth and throat, not the ears.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?

Correct Answer is A

Explanation

The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

Which general survey question focuses on the common "fifth vital sign"?

The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use?

During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer?

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address?