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 ["A","B","C","E"]
Explanation
A. Distractions such as music. Music and other distractions, such as guided imagery or television, can help shift the patient's focus away from pain, reducing discomfort and anxiety.
B. Massage. Gentle massage can help promote relaxation, improve circulation, and reduce muscle tension, which may enhance pain relief when used alongside medication.
C. Cold or heat applications. Cold therapy can help reduce inflammation and swelling, while heat therapy can improve blood flow and relax muscles, making them effective in managing arthritis pain and post-surgical discomfort.
D. Vigorous rubbing of the joints. Vigorous rubbing could worsen pain and cause irritation, particularly in a patient with arthritis and post-surgical pain. Gentle approaches are more appropriate.
E. Relaxation techniques. Deep breathing, guided imagery, and progressive muscle relaxation can help lower stress and enhance the body's ability to manage pain.
Correct Answer is B
Explanation
A. An unconscious, intubated patient. An oral temperature is not appropriate for an unconscious or intubated patient due to the risk of injury and inability to follow instructions. A tympanic, rectal, or axillary method would be preferred.
B. A patient with bilateral middle ear infections. Tympanic thermometers measure temperature through the ear canal and tympanic membrane, which can be affected by infection or inflammation, leading to inaccurate readings. An oral or alternative method is preferred.
C. An agitated patient who cannot follow directions. Oral temperature requires cooperation, so it would not be suitable for an agitated patient who may bite or not keep the thermometer in place. A tympanic or axillary method would be better.
D. A patient with gastroenteritis who is vomiting. Vomiting can make oral temperature measurement uncomfortable and impractical. A tympanic, axillary, or rectal method would be more appropriate.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.