Nokea
Upon assessing the vital signs of a 56-year-old male, you find that he has an apical pulse of 71 bpm and a radial pulse of 62 bpm. Which of the following numbers would be correct to document as the pulse deficit?
- B. 3
- C. 7
- D. 9
- E. 133
Correct Answer: D
Rationale: Pulse deficit is the difference between apical (71) and radial (62) pulses, which is 9.
You may also like to solve these questions
In which situations would it be inappropriate to delegate the vital sign assessment?
- A. Routine vital signs on a patient with pneumonia
- B. A patient whose level of consciousness has gone from alert to responding only to pain stimuli
- C. A teenager admitted with influenza A whose temperature 2 hours ago was 100.6°F orally
- D. A confused and lethargic patient brought to the emergency room after being involved in an automobile accident
- E. An adult patient who becomes diaphoretic and pale and complains of sudden onset of severe left chest pain while ambulating in the hallway
Correct Answer: B,D,E
Rationale: Vital signs require nursing assessment in unstable conditions like altered consciousness, confusion, or acute chest pain.
You must assess the temperature of an 89-year-old female who is confused, hostile, and combative. Which route would be most appropriate to use?
- A. Rectal
- B. Oral
- C. Temporal
- D. Axillary
Correct Answer: C
Rationale: Temporal route is non-invasive, safe, and accurate for confused or combative patients.
Uncontrolled hypertension can result in permanent damage of which organs?
- A. Heart and eyes
- B. Pancreas and spleen
- C. Large intestine and skeletal structures
- D. Brain and kidneys
- E. Urinary bladder
Correct Answer: A,D
Rationale: Hypertension damages the heart, eyes, brain, and kidneys due to increased vascular pressure.
A 68-year-old African American female is admitted for hypertension. She is at risk for hypertension based on which of the following?
- A. Smoking
- B. Obesity
- C. Lower cholesterol level in the blood
- D. Moderate to heavy alcohol consumption
- E. Low stress level
Correct Answer: A,B,D
Rationale: Smoking, obesity, and alcohol consumption are modifiable risk factors for hypertension.
Which of the following objective vital signs, all taken on adults, have one or more components that fall outside of typical normal ranges?
- A. BP - 118/66 mm Hg, T - 99.2°F, P - 74 regular and strong, R - 17, O2 sats - 99%
- B. BP - 98/62 mm Hg, T - 98.2°F, P - 98 regular and strong, R - 20, O2 sats - 97%
- C. BP - 142/92 mm Hg, T - 98.4°F, P - 62 regular and bounding, R - 14, O2 sats - 96%
- D. BP - 120/74 mm Hg, T - 100.6°F, P - 86 regular and strong, R - 24, O2 sats - 98%
Correct Answer: B,C,D
Rationale: Normal ranges: BP 100-130/60-80, T 97.8-99°F, P 60-100, R 12-20. Options B (low BP), C (high BP), and D (high T, R) are abnormal.