The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

The use of two middle fingers lightly applied to area along the thumb side of the wrist.

Application of firm pressure on the wrist area along the side of the fifth digit.

Application of the bell of the stethoscope to the antecubital area of the upper extremity.

Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Answer and Explanation

The Correct Answer is A

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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Correct Answer is B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. Vesicular breath sounds B. Adventitious breath sounds C. Bronchial breath sounds D. Bronchovesicular breath sounds

Correct Answer is C

Explanation

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

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The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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