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.

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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.

A. Vesicular B. Tracheal C. Bronchial D. Bronchovesicular

Correct Answer is A

Explanation

A. Vesicular: Vesicular breath sounds are normal and are heard over most of the lung fields. They are soft and low-pitched.

B. Tracheal: Tracheal breath sounds are harsh and high-pitched, typically heard over the trachea rather than over most of the lung fields.

C. Bronchial: Bronchial breath sounds are loud and high-pitched, usually heard over the trachea and larynx, not over most lung areas.

D. Bronchovesicular: These sounds are heard between the sternum and the interscapular area but are not as commonly heard over most of the lung fields compared to vesicular sounds.

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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.)

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Naxlex Comprehensive Predictor Exams

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