Vital signs post test 3 - After reviewing the material use this to study for the post-test. PDF

Preview

Summary

After reviewing the material use this to study for the post-test....

Description

1. The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) A.

An apical pulse of a patient who is to receive a cardiac drug.

B.

A radial pulse on a patient with a 1200 mL fluid restriction. Correct

C.

A radial pulse of a patient in the emergency room with chest pain.

D.

A femoral pulse following a lower leg amputation.

E. The temporal pulse of a child. Correct The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site. Awarded 2.0 points out of 2.0 possible points. 2. 2.ID: 18668356566 Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A.

An elderly patient with Type 1 diabetes who is otherwise healthy.

B.

The patient who was just informed of a diagnosis of cancer. Correct

C.

A patient with peripheral vascular disease. Correct

D.

A patient who is receiving bolus IV fluids. Correct

E. A patient with Alzheimer's disease. Certain conditions place patients at risk for pulse alterations. This may include a person with cardiovascular disease, a patient who is experiencing anxiety, and a patient who received a sudden infusion of IV fluids. Uncomplicated diabetes and Alzheimer's disease fail to directly relate to pulse alteration. Awarded 3.0 points out of 3.0 possible points. 3. 3.ID: 18668356568 Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? A. B.

C.

Check the carotid pulses one side at a time. Auscultate the apical pulse for quality and rate. Correct The nurse should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. The pulse on the opposite side should also be assessed to see if the alteration is happening bilaterally, in addition to assessing the apical pulse. Reassess the radial pulse for 30 seconds.

D. Check the radial pulse on the opposite side. Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 18668356560 What is the normal pulse range for an adult? A.

120 to 160 beats per minute.

B.

90 to 140 beats per minute.

C.

60 to 100 beats per minute. Correct The normal pulse range for an adult is 60 to 100 beats per minute. The pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute.

D. 50 to 80 beats per minute. Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 18668356562 The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. A.

True.

B.

False. Correct For routine auscultation of the apical pulse, you should rely on the diaphragm side of the chest piece because it is designed to pick up higher-pitched heart sounds like that of the apical pulse.The bell side of the stethoscope should be used to assess heart sounds to identify murmurs. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 18668356570 In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) A.

A newborn following a heelstick.

B.

A patient returning from the operating room. Correct

C.

A patient who received morphine for pain. Correct

D.

A student who is getting ready to take an exam.

E. A patient who experienced a bleeding episode. Having general anesthesia or receiving an opioid analgesic may decrease the pulse rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the heart attempts to compensate to maintain cardiac output. Awarded 2.0 points out of 2.0 possible points. 7. 7.ID: 18668356564 The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) A.

The NAP is assessing for a pulse on the ulnar side of the wrist. Correct

B.

The NAP is pressing down too hard on the patient’s radial site. Correct

C.

The NAP is assessing for a pulse on the thumb side of the wrist.

D.

The NAP failed to auscultate the patient’s wrist with a stethoscope.

E.

The patient was previously reported to have a full, bounding pulse.

F. The NAP assessed the patient’s BP before taking the patient’s pulse. The radial pulse is found on the radial (thumb) side of the wrist. Pressing too hard on the radial site may obliterate the pulse; light pressure should be used. A weak, thready pulse may be difficult to palpate, not a full, bounding pulse. The pulse is palpated, not auscultated, at the radial site. If a pulse is to be auscultated, it is done so at the PMI. The order of vital sign assessment should not affect the ability to obtain a patient’s radial pulse.If not selected (incorrect). The radial pulse is found on the radial (thumb) side of the wrist. Pressing too hard on the radial site may obliterate the pulse; light pressure should be used. A weak, thready pulse may be difficult to palpate, not a full, bounding pulse. The pulse is palpated, not auscultated, at the radial site. If a pulse is to be auscultated, it is done so at the PMI. The order of vital sign assessment should not affect the ability to obtain a patient’s radial pulse. Awarded 2.0 points out of 2.0 possible points....