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What is the primary purpose of pulse assessment?
- A. Assessing changes in blood pressure
- B. Assessing changes in body temperature
- C. Assessing changes in cardiac status
- D. Assessing changes in respiratory status
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (A) relates but requires a cuff. Temperature (B) isn't pulse-related. Respiratory status (D) is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
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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 patient has a temperature of 105.2?°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
- A. Radiation
- B. Conduction
- C. Convection
- D. Evaporation
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction (B), transferring heat from the skin to the cooler objects through direct contact. Radiation (A) involves heat loss to the environment without contact, not the primary method here. Convection (C) requires air movement (e.g., fans), not used. Evaporation (D) occurs with moisture vaporizing, a minor effect with tepid water but not dominant. Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.
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 nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
- A. Apply more pressure to the radial artery to feel pulse.
- B. Notify the health care provider of the findings.
- C. Tell the patient to expect these symptoms occasionally.
- D. Recheck the vital signs in an hour.
Correct Answer: B
Rationale: Light-headedness, irregular pulse, and a BP drop (100/72 from 113/80) suggest instability (e.g., arrhythmia). Notifying the provider (B) ensures prompt evaluation. More pressure (A) won't clarify irregularity. Dismissing symptoms (C) or delaying (D) risks deterioration. Choice B is correct, per nursing escalation protocols.
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.