How should the nurse assess the carotid pulse?

Palpate firmly with two fingers in the inguinal space between the umbilicus and the symphysis pubis

Palpate each carotid pulse independently, at the medial sternomastoid muscle

Place the finger tips gently between the bicep and tricep muscle

Place two fingers of each hand on the right and left side of the neck where bounding pulsation is noted

Answer and Explanation

The Correct Answer is B

A. Palpate firmly with two fingers in the inguinal space between the umbilicus and the symphysis pubis:
That describes femoral pulse, not carotid.

B. Palpate each carotid pulse independently, at the medial sternomastoid muscle:
This ensures accurate palpation and prevents vagal stimulation or compromising blood flow to the brain.

C. Place the finger tips gently between the bicep and tricep muscle:
That describes assessment of the brachial pulse, not carotid.

D. Place two fingers of each hand on the right and left side of the neck where bounding pulsation is noted:
Never palpate both carotids simultaneously-it can decrease cerebral blood flow and cause syncope.

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Correct Answer is D

Explanation

A. The tips of the scapula:
Approximates the 7th rib area but not the base of the lungs.

B. The bottom of the ribcage:
Too vague and imprecise as a landmark; the ribcage varies in individuals.

C. The stomach:
Refers to an abdominal organ-not an appropriate thoracic landmark.

D. Thoracic vertebra #10 (T10):
This is the posterior landmark for the bases of the lungs during normal respiration.

A. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. B. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. C. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours. D. J.M. came into the clinic complaining of having black stools for the past 24 hours.

Correct Answer is C

Explanation

A. J.M. is a 59-year-old man seeking treatment for ulcerative colitis:
This documents a chronic condition, but not the acute reason for the visit (black stools).

B. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked:
Vague and less focused on the acute symptom prompting the visit.

C. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours:
Focuses on the subjective reason for seeking care, using the patient’s own words, as recommended.

D. J.M. came into the clinic complaining of having black stools for the past 24 hours:
Avoids using the word "complaining," which can be judgmental; also doesn’t quote the patient's exact words.

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How should the nurse assess the carotid pulse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When auscultating the lungs to assess breath sounds, what anatomical landmark will indicate the bases of the lung fields?

Correct Answer is D

Explanation

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the past 24 hours. How would the nurse best document his reason for seeking care?

Correct Answer is C

Explanation

To ensure privacy while assessing a patient in a shared hospital room, the nurse needs to use curtains to achieve:

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