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 B
Explanation
A. Brachial artery. The brachial pulse is commonly used in infants but is not the best choice for assessing circulation in an unconscious adult.
B. Carotid artery. The carotid artery is the preferred site for assessing a pulse in an unconscious adult because it is a central pulse with strong circulation, even in low-perfusion states.
C. Radial artery. The radial pulse is a peripheral pulse and may be difficult to palpate if the patient has poor circulation or cardiac arrest. The carotid pulse is more reliable in emergencies.
D. Apical artery. There is no apical artery; the apical pulse is auscultated over the heart with a stethoscope and is not used in emergency pulse checks.
Correct Answer is ["50.9"]
Explanation
Calculation:
To convert pounds to kilograms, use the formula:
Kg = lb/2.2
Substituting the given value:
Kg = 112.2/2.2
= 50.9kg
Thus, 112.2 lb = 50.9 kg.
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