The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2°F; pulse, 68 beats/minute, thready: respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?

Palpable

Within normal limits

Thready

Answer and Explanation

The Correct Answer is C

A. Palpable: This describes whether the pulse can be physically felt, which is useful for assessing circulation but does not answer the physician’s request. Pulse pressure is a numerical value, not a descriptive term, and cannot be reported as "palpable."
B. Within normal limits: This is a nonspecific and subjective response. It does not provide the precise data the physician requested. Accurate clinical communication requires the nurse to report the actual pulse pressure value to aid in diagnosis and treatment decisions.
C. 24: Pulse pressure is calculated by subtracting diastolic from systolic pressure (102 − 78 = 24 mm Hg). This value is low and may indicate decreased cardiac output, early shock, or heart failure. It is the correct and medically appropriate response to the physician’s question.
D. Thready: This term refers to the strength or amplitude of the pulse, often noted during palpation. Although it suggests poor perfusion, it does not provide a quantitative measurement. It’s unrelated to the actual calculation of pulse pressure, which is what the physician needs.

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Correct Answer is B

Explanation

A. Monitor heart rhythm: While cardiac monitoring is important, it doesn’t directly assess airway status or ventilation. Respiratory compromise must be identified through airway-focused assessments.
B. Auscultate lung sounds: Hourly lung auscultation helps detect early signs of airway obstruction, stridor, or atelectasis. It’s the most direct way to monitor for post-extubation respiratory issues.
C. Assess capillary refill: Capillary refill assesses peripheral perfusion but gives little information about airway patency or breathing effectiveness after extubation.
D. Obtain vital signs: Vital signs are useful but may not change until respiratory compromise becomes severe. Lung assessment provides earlier clues of deterioration.

A. The client should have a bowel movement every day to avoid development of an intestinal obstruction. B. The client can develop a rectal fissure, which will increase pain levels. C. The client should not develop hemorrhoids. D. Straining engages the Valsalva maneuver, which can cause dangerous effects.

Correct Answer is D

Explanation

A. The client should have a bowel movement every day to avoid development of an intestinal obstruction: While regular bowel movements are important, going two days without one is not uncommon and does not usually lead to obstruction. The priority in heart failure is avoiding strain, not frequency alone.
B. The client can develop a rectal fissure, which will increase pain levels: Although rectal fissures can occur with hard stools, they are not the primary concern in a heart failure patient. The hemodynamic effects of straining pose a greater immediate risk.
C. The client should not develop hemorrhoids: Preventing hemorrhoids is beneficial but not critical in the context of heart failure. The concern with straining extends beyond local complications like hemorrhoids to systemic cardiovascular effects.
D. Straining engages the Valsalva maneuver, which can cause dangerous effects: The Valsalva maneuver increases intrathoracic pressure, reducing venous return and cardiac output. In clients with heart failure, this can trigger arrhythmias, syncope, or even cardiac decompensation, making stool softeners essential for prevention.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Correct Answer is B

Explanation

A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?

Correct Answer is D

Explanation

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

A client who is a nursing student reports increased anxiety with test taking. Which behavioral technique is most appropriate for this client to put into practice?

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?

A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed?

The nurse is caring for a client who is having a mitral valve replacement with a mechanical valve. What instructions should the nurse be sure the client understands prior to being discharged?