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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.
Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.
Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.
Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.
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