The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding?
4+
3+
2+
1+
The Correct Answer is D
A. 4+. A 4+ pulse is bounding and strong, often seen in conditions like fever, anemia, or fluid overload. This does not match the description of a weak pulse.
B. 3+. A 3+ pulse is stronger than normal but not bounding. This is not considered weak.
C. 2+. A 2+ pulse is normal and easily palpable, which does not indicate the weakened pulse described in the patient.
D. 1+. A 1+ pulse is weak and thready, meaning it is difficult to palpate and easily disappears with slight pressure. This grading is appropriate for a hypotensive patient with poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Choose a cuff that is the right size. Using the correct cuff size is essential for accurate blood pressure readings. A cuff that is too small can falsely elevate readings, while a cuff that is too large can falsely lower them.
B. Support the extremity. The arm should be supported at heart level to prevent unnecessary muscle strain, which could affect blood pressure readings. An unsupported arm may lead to an artificially higher reading.
C. Have the patient cross their legs while taking blood pressure. Crossing the legs can increase blood pressure by reducing venous return and increasing vascular resistance, leading to inaccurate measurements. The patient should keep their feet flat on the floor.
D. Ensure proper cuff application. The cuff should be placed snugly around the upper arm with the artery marker positioned correctly over the brachial artery. Improper placement can lead to inaccurate readings.
E. Ensure that the patient is sitting or lying. Blood pressure should be measured while the patient is in a stable position—either sitting with feet flat on the floor or lying down. Standing may result in postural changes that can alter blood pressure readings.
Correct Answer is ["3"]
Explanation
Calculation:
To determine the number of capsules per dose, use the formula:
Capsules per dose = Dose ordered/ Dose available
Given:
- Ordered dose = 600 mg
- Available dose = 200 mg per capsule
Capsules per dose = 600mg/ (200mg/capsule)
= 3 capsules
Thus, the nurse will administer 3 capsules per dose.
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