The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

Increased, strong

Diminished, weaker than expected

Absent, unable to palpate

Bounding

Answer and Explanation

The Correct Answer is A

A. Increased, strong:

A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.

B. Diminished, weaker than expected:

This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.

C. Absent, unable to palpate:

If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.

D. Bounding:

A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Discard the bottle of saline and obtain a new bottle:

Sterility is crucial when performing a sterile procedure. If the saline solution has been opened for 48 hours, it may no longer be considered sterile. The nurse's priority is to use a fresh, sterile bottle of saline to ensure aseptic technique during the dressing change.

B. Lip the bottle of saline over the trash before pouring into the field:

Lipping the bottle over the trash is not a recommended practice. Pouring the saline over a sterile field is the appropriate way to maintain the sterility of the solution.

C. Pour the saline at least 6 inches above the sterile field:

While pouring from a height can help generate a flow without contamination, the priority in this situation is to address the sterility of the saline. It's crucial to start with a new, unopened bottle.

D. Be sure the label is facing the palm before pouring:

The orientation of the label is not the primary concern in this scenario. The primary concern is the sterility of the saline solution.

A. Do not let the patient know you are counting their respirations B. Let the patient rest for 5 minutes before you measure their blood pressure C. Do not measure the patient’s temperature rectally D. Count the patient’s radial pulse for 30 seconds and multiply it by 2

Correct Answer is C

Explanation

A. Do not let the patient know you are counting their respirations:

This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.

B. Let the patient rest for 5 minutes before you measure their blood pressure:

Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.

C. Do not measure the patient’s temperature rectally:

Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.

D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:

Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.

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 taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Correct Answer is A

Explanation

A nurse is caring for a patient who has a low platelet count and is at risk for bleeding. Which of the following is a critical factor or priority that the nurse should apply when considering how to obtain the patient’s vital signs?

Correct Answer is C

Explanation

Nursing in the United States is regulated by the state nurse practice act. What is a common element of each state’s nurse practice act?

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

Which of the following interventions would best assist the nurse in breaking the chain of infection for all clients?

During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

The nurse would recognize which of the following patients would be at highest risk for developing an infection?

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?