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The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
- A. Radial
- B. Brachial
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: In infants, the brachial artery (B) is preferred for pulse due to accessibility and strength; radial (A) is weak and hard to palpate. Femoral (C) and popliteal (D) are less practical. Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.
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The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
- A. You can apply the cuff in any manner.
- B. You will need to recalibrate the machine.
- C. You can move your arm during the reading.
- D. You will need to use a stethoscope properly.
Correct Answer: B
Rationale: Portable BP devices require recalibration (B) for accuracy, a key teaching point. Random cuff placement (A) or arm movement (C) skews readings. Stethoscopes (D) aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
- A. Red blood cell count of 5.0 million/mm3
- B. Hemoglobin level of 8.0 g/100 mL
- C. Hematocrit level of 45%
- D. Pulse oximetry of 95%
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL (B) indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 (A) and hematocrit 45% (C) are normal. Oximetry 95% (D) is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
- A. 138/70
- B. 138/62
- C. 70/62
- D. 138/70/62
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 (B). Muffling (70) is phase IV, not standard for adults. 138/70 (A) uses muffling incorrectly. 70/62 (C) is invalid. 138/70/62 (D) isn't standard. Choice B is correct, per AHA guidelines.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
The nurse needs to take the temperature of a patient who had a cardiac arrest. Which route will the nurse use?
- A. Oral
- B. Rectal
- C. Tympanic
- D. Temporal
Correct Answer: C
Rationale: Post-cardiac arrest, tympanic (C) provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral (A) risks inaccuracy post-arrest. Rectal (B) is invasive and slow. Temporal (D) is less reliable in emergencies. Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.