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The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
- A. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.
- B. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist.
- C. Place the thumb over the groove along the little finger side of the patient's wrist.
- D. Place the thumb over the groove along the thumb side of the patient's wrist.
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove (A), ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.
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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.
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.
A nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.
The nurse is caring for an older-adult patient and notes that the temperature is 96.8?°F (36?°C). How will the nurse interpret this?
- A. This is normal for an older adult.
- B. This is too high for an older adult.
- C. This is indicative of infection.
- D. This requires immediate intervention.
Correct Answer: A
Rationale: Older adults often have lower baseline temperatures (e.g., 96.8?°F) due to slower metabolism; (A) is normal. Too high (B) or infection (C) doesn't fit without symptoms. Intervention (D) is unnecessary. Choice A is correct, per geriatric nursing norms.
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
- A. Radial
- B. Brachial
- C. Carotid
- D. Popliteal
Correct Answer: C
Rationale: In deteriorating patients, carotid (C) provides a strong, accessible pulse, reliable even in low perfusion, unlike radial (A) or brachial (B). Popliteal (D) is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.