The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding?

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.

A. Walt 30 minutes and take an oral temperature B. Advise the patient to drink a glass of cold water C. Take a rectal temperature D. Take the oral temperature as planned

Correct Answer is A

Explanation

A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse?

Correct Answer is C

Explanation

You have delegated vital signs to the assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to

Correct Answer is A

Explanation

Exhibits Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select the 4 correct answers (Case Study #2)

While inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

The physician orders ibuprofen 600 mg po prn for cramping. The medication is supplied in 200-mg capsules. How many capsules will the nurse administer?

A postoperative patient is using patient-controlled analgesia (PCA) pump. You will evaluate the effectiveness of the medication when

Which patient should have the temperature taken orally rather than using a tympanic thermometer?

Which technique will provide the most accurate measurement of the patient's core temperature?

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

A patient with high gastric residuals has Reglan 10mg every 6 hours via tube ordered. Available: Reglan syrup 10mg/10mL. How many milliliters will the nurse administer with each dose? mL. (Shade CUP #1 on the supplemental handout)