The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?
An oral temperature of 100°F (37.8°C)
A respiratory rate of 30/min.
A radial pulse of 45 beats in 30 seconds.
A blood pressure of 114/74 mmHg.
The Correct Answer is C
Choice A rationale:
This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.
Choice B rationale:
This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.
Choice C rationale:
Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.
Choice D rationale:
Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.
Choice B rationale:
This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.
Choice C rationale:
This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.
Choice D rationale:
This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.
Correct Answer is A
Explanation
Choice A rationale:
Diastolic pressure represents the pressure in the arteries when the heart is at rest between contractions. It specifically measures the force of blood against the arterial walls when both the atria and ventricles are relaxed, allowing the heart to fill with blood. Diastolic pressure is the bottom number in a blood pressure reading (e.g., 120/80 mmHg), indicating the pressure in the arteries during the heart's resting phase. Elevated diastolic pressure is an important indicator of increased risk for cardiovascular diseases, such as hypertension.
Choice B rationale:
This statement describes systolic blood pressure, which measures the pressure in the arteries when the heart's ventricles contract and pump blood into the circulation. Systolic pressure is the top number in a blood pressure reading (e.g., 120/80 mmHg) and represents the highest pressure reached in the arteries during a cardiac cycle.
Choice C rationale:
This description is not accurate for either diastolic or systolic pressure. Both atria and ventricles do not contract simultaneously; they follow a specific sequence to ensure effective pumping of blood through the heart.
Choice D rationale:
This statement is incorrect as it does not align with the definitions of diastolic or systolic blood pressure. Diastolic pressure specifically measures the pressure in the arteries during the heart's resting phase, not when the ventricles relax. .
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