Your 95-year-old client's vital signs are as follows: oral T 98.6 F: P (radial) 84 with irregularity: R 18. normal depth, & regular: BP (left arm, sitting) 140/86. Which nursing assessment(s) would be done to obtain more data at this time?
Positional BP readings
Carotid pulse and temperature
Full respiratory system assessment
Apical pulse for one minute
The Correct Answer is D
A. Positional BP readings. While orthostatic blood pressure readings can assess for postural hypotension, there is no indication in the current vitals that the client is experiencing symptoms such as dizziness or syncope.
B. Carotid pulse and temperature. The client’s temperature is already documented as normal, and the carotid pulse is not needed when an irregular radial pulse has been noted. The apical pulse is the preferred method to assess for irregularities.
C. Full respiratory system assessment. The respiratory rate is within the normal range, with regular rhythm and normal depth, so a full respiratory assessment is not the immediate priority.
D. Apical pulse for one minute. An irregular radial pulse suggests the possibility of an arrhythmia. The apical pulse provides a more accurate assessment of heart rhythm and rate, ensuring a complete evaluation of the irregularity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.3"]
Explanation
Calculation:
Formula:
Dose to administer (mL) = Ordered dose (mcg) / Available dose (mcg/mL)
Given:
Ordered dose: 400 mcg.
Available dose: 300 mcg/mL.
Volume (mL) = 400 mcg / 300 mcg/mL
= 1.333... mL
Rounded to the nearest tenth: 1.3 mL.
The nurse will administer 1.3 mL of Neupogen.
Correct Answer is ["A","B","C"]
Explanation
A. Pulse of smooth contour with 2+ amplitude. A normal pulse should have a smooth upstroke and downstroke with a moderate (2+) amplitude, indicating adequate blood flow and cardiac function.
B. Heart rate of 62 beats/min. A normal resting heart rate for a healthy adult range from 60 to 100 beats per minute. A heart rate of 62 bpm is within this normal range.
C. S1 and S2 present with regular rhythm. The first (S1) and second (S2) heart sounds should be audible and regular, indicating normal closure of the heart valves and a steady cardiac rhythm.
D. Mild, pedal edema. Pedal edema is not a normal finding in a healthy adult and may indicate fluid retention or cardiovascular issues such as heart failure or venous insufficiency.
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