The nurse is taking vital signs. The patient’s radial pulse has an irregular rhythm. What should the nurse do next?

Assess the patient’s blood pressure.

Check the patient’s apical pulse rate and rhythm.

Obtain the pulse in the other arm.

Notify the patient’s primary health care provider.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing blood pressure is important but does not directly confirm an irregular pulse. An irregular radial pulse may indicate arrhythmias like atrial fibrillation, affecting cardiac output. Blood pressure measurement assesses hemodynamic status but cannot verify pulse rhythm accuracy, as it relies on arterial pressure, not direct cardiac electrical activity, making it a secondary step.

Choice B reason: Checking the apical pulse, auscultated at the heart’s apex, directly assesses cardiac rhythm and rate, confirming an irregular radial pulse. Irregular rhythms, like atrial fibrillation, disrupt normal atrial-ventricular conduction, detectable via auscultation. This step ensures accurate assessment of cardiac electrical activity and stroke volume, critical for identifying arrhythmias and guiding further interventions.

Choice C reason: Obtaining the pulse in the other arm may detect peripheral inconsistencies but does not confirm cardiac rhythm. An irregular radial pulse likely reflects a cardiac arrhythmia, not a localized vascular issue. Apical pulse assessment directly evaluates heart activity, making it more relevant than bilateral radial checks for verifying rhythm disturbances and planning appropriate interventions.

Choice D reason: Notifying the healthcare provider is premature without confirming the irregular rhythm. An irregular pulse may indicate an arrhythmia, requiring validation via apical pulse to assess cardiac electrical activity. Immediate notification bypasses critical assessment steps, potentially leading to misdiagnosis or delayed care, as the nurse must first gather accurate data to inform the provider.

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Correct Answer is C

Explanation

Choice A reason: Stating fats are mostly from animal sources is inaccurate, as plant sources (e.g., oils, nuts) also provide significant fats. A low-fat diet reduces cardiovascular risk by limiting saturated and trans fats, which raise LDL cholesterol. This statement oversimplifies fat sources, ignoring plant-based fats like olive oil, which are beneficial, making it incorrect.

Choice B reason: Unsaturated fats, including monounsaturated and polyunsaturated, are primarily from plant sources (e.g., avocados, fish), not animal sources. These fats lower LDL cholesterol, benefiting cardiovascular health. The statement is incorrect, as a low-fat diet encourages unsaturated fats over saturated, which are animal-derived, making this misinformation for dietary education.

Choice C reason: Trans fats, found in processed foods, raise LDL and lower HDL cholesterol, increasing cardiovascular risk. Guidelines recommend keeping trans fat below 7% of total calories to minimize atherosclerosis. This is critical for a low-fat diet, as trans fats disrupt lipid metabolism and endothelial function, making this the correct information to share with the patient.

Choice D reason: Polyunsaturated fats, like omega-3s, should not be limited to less than 7% of calories, as they reduce LDL and inflammation, benefiting heart health. A low-fat diet encourages these fats over trans or saturated fats. This statement is incorrect, as polyunsaturated fats support cardiovascular and metabolic health, not requiring such strict limitation.

A. Cyanosis B. Wheezing C. Decreased level of consciousness D. Frequent coughing

Correct Answer is C

Explanation

Choice A reason: Cyanosis, a bluish skin discoloration, indicates hypoxemia in COPD due to impaired gas exchange in damaged alveoli. While concerning, it is a common chronic symptom and not immediately life-threatening unless rapidly worsening. Decreased level of consciousness signals severe hypoxia affecting cerebral oxygenation, requiring urgent reporting over stable cyanosis.

Choice B reason: Wheezing results from airway obstruction in COPD, caused by bronchoconstriction and mucus accumulation, reducing airflow. It’s a chronic symptom managed with bronchodilators. While important, it does not indicate acute decompensation like decreased consciousness, which reflects critical cerebral hypoxia and requires immediate intervention to prevent brain damage.

Choice C reason: Decreased level of consciousness indicates severe hypoxia in COPD, as low oxygen saturation impairs cerebral function. Brain cells require constant oxygen for ATP production via aerobic metabolism. Hypoxia reduces cerebral perfusion, causing confusion or unresponsiveness, signaling a life-threatening emergency. This finding warrants immediate reporting to address acute respiratory failure.

Choice D reason: Frequent coughing in COPD results from mucus production and airway irritation, a common chronic symptom. It aids in clearing secretions but does not indicate acute decompensation. Unlike decreased consciousness, which reflects severe cerebral hypoxia, coughing is less urgent and managed with expectorants or airway clearance techniques, not immediate reporting.

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The nurse is taking vital signs. The patient’s radial pulse has an irregular rhythm. What should the nurse do next?

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