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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Posterior-to-anterior comparison. While both the anterior and posterior lung fields should be assessed, auscultation should be performed in a systematic side-to-side manner rather than switching between front and back.
B. Side-to-side comparison. The correct method for auscultating breath sounds is to compare sounds bilaterally (right lung to left lung) at each level. This helps identify asymmetrical lung sounds, which could indicate conditions like pneumonia, pleural effusion, or atelectasis.
C. Top-to-bottom comparison. While lung auscultation progresses from the apices to the bases, it should always be done in a side-to-side manner to detect differences between the lungs.
D. Interspace-by-interspace comparison. Although breath sounds are assessed at different intercostal spaces, the key principle is to compare sounds bilaterally at each level, rather than focusing solely on individual interspaces.

Correct Answer is ["2"]

Explanation

Calculation:

To determine the number of tablets per dose, use the formula:

Tablets per dose = Dose ordered/ Dose available

Given:

Ordered dose = 10 mg
Available dose = 5 mg per tablet

Tablets per dose = 10mg/ (5mg/tablet)

= 2 tablets

Thus, the nurse will administer 2 tablets per dose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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