Nokea
Another nurse working on your floor reports that one of the patients has an apical pulse of 87 bpm and a pulse deficit of 9. You know that means the patient's radial pulse was
- A. 96 bpm
- B. 87 bpm with 9 skips
- C. 78 bpm
- D. 9 bpm
Correct Answer: C
Rationale: Pulse deficit is the difference between apical and radial pulse rates; 87 bpm (apical) - 9 = 78 bpm (radial).
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Which of the two heart sounds is the loudest?
- A. S1
- B. S2
- C. S3
- D. S4
Correct Answer: A
Rationale: S1 is typically louder than S2 because it involves the closure of the mitral and tricuspid valves, which produce a stronger sound.
Describe the assessments that you will perform to establish the status of his renal system and ensure that he is not getting into fluid overload problems.
- A. Urine output, weight, edema, breath sounds
- B. Blood pressure, serum creatinine, BUN
- C. Fluid intake, electrolyte levels, lung auscultation
- D. All of the above
Correct Answer: D
Rationale: Renal system assessment includes urine output, weight, edema, breath sounds, blood pressure, serum creatinine, BUN, fluid intake, and electrolyte levels to monitor for fluid overload.
If you hear a shrill, high-pitched, crowing sound coming from the room of a 3-year-old child who has croup, you recognize the ominous sign known as
- A. Crackles
- B. Rhonchi
- C. Wheezes
- D. Pleural friction rub
- E. Stridor
Correct Answer: E
Rationale: Stridor is a high-pitched, crowing sound associated with upper airway obstruction, common in croup.
During a focused assessment of a patient's circulatory system, you were unable to palpate the left pedal pulse although the right pedal pulse was strong. What should be your first action?
- A. Notify the health-care provider
- B. Check the blood pressure in the left leg
- C. Palpate for the left posterior tibialis pulse
- D. Obtain a Doppler
Correct Answer: D
Rationale: Using a Doppler is the first step to assess an absent pedal pulse, as it can detect blood flow that is not palpable.
The acronym PMI stands for what? Which means what?
- A. Point of maximum impulse, strongest heart beat
- B. Pulse measurement index, pulse strength
- C. Primary medical inspection, initial assessment
- D. Point of mitral intensity, mitral valve sound
Correct Answer: A
Rationale: PMI stands for 'point of maximum impulse,' the location where the heart's apex beat is strongest, typically at the 5th intercostal space.