Nokea
The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this?
- A. Palpate a radial pulse in both wrists for 30 seconds
- B. Auscultate the apical pulse for 60 seconds
- C. Take a second nurse with you to palpate the radial pulse at the same time that you auscultate the apical pulse for 60 seconds
- D. Palpate the PMI for a full minute
Correct Answer: B
Rationale: Auscultating the apical pulse for 60 seconds provides the most accurate heart rate, especially for irregular rhythms.
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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.
What are the acronyms used to indicate the quadrants of the abdomen?
- A. RLQ
- B. LMQ
- C. LUQ
- D. RMQ
- E. RUQ
- F. LLQ
Correct Answer: A,C,E,F
Rationale: The abdomen is divided into four quadrants: RLQ (right lower quadrant), LUQ (left upper quadrant), RUQ (right upper quadrant), and LLQ (left lower quadrant).
While assessing the patient's oral mucosa, you detect severely unpleasant sour breath. What is the correct medical terminology for this finding?
- A. Halitosis
- B. Fetor oris
- C. Malodor
- D. Xerostomia
Correct Answer: A
Rationale: Halitosis is the medical term for bad breath, including sour or unpleasant odors from the mouth.
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.
You know that it is important to foster rapport and communication with all of your patients. Which of the following actions and interventions would be helpful to increase the effectiveness of your communication and increase nurse-patient rapport?
- A. Talk most of the time you are with the patient so that he or she does not get nervous
- B. Smile frequently
- C. Think of a good nickname you can call the patient to put him or her at ease
- D. Sit in a chair beside the bed and give the patient at least 5 to 10 minutes of your time
- E. Smile and be genuine
- F. Always introduce yourself while you are smiling and explain what you are about to do before you perform an intervention or assessment
- G. Be aware of possible cultural restrictions or influences. Verify them when uncertain
Correct Answer: B,D,E,F,G
Rationale: Smiling, spending time, being genuine, explaining actions, being nonjudgmental, and respecting cultural differences foster rapport and effective communication.