Evolve quiz Flashcards
(105 cards)
What is the primary purpose of initially assessing an apical pulse
Establishment of a baseline as part of the patients vital signs
What instruction should the nurse give assistive personnel regarding the appropriate technique when measuring the adult patients apical pulse
Place your stethoscope at the fifth intercostal space of the left midclavicular line
Which action would take priority if a patients apical pulse has an irregular rhythm
Reassess the pulse for 1 whole minute
Which statement demonstrates an understanding of the importance of communicating changes in the patients apical pulse rate
The apical pulse increased from 78 to110 but the patient had just returned from the bathroom
The nurse can best determine the effect of crying on a patients apical pulse by doing what
Comparing the patients post crying apical pulse rate with her baseline or previous rate
What is the major health problem resulting from a pulse deficit
Deceased cardiac output is the major problem indicated by a pulse deficit. Decreased cardiac output may lead to other problems, such as activity intolerance
What should the nurse do when a pulse deficit is suspected
Ask another health care provider to count the radial pulse while the nurse counts the apical pulse
Which action should the nurse perform after identifying a pulse deficit
Assess the patient for signs of decreased cardiac output
You have the following information:
Oral temp = 38.6 C, radial pulse = 112 weak and thread, apical pulse =117 regular, respiration’s = 24 regular, BP = 104/50 right arm and 102/50 left arm
What is the pulse deficit
5
Take difference between apical and radial pulse
Which of the following is an early manifestation of decreased cardiac output
Fatigue
During the admissions process, the nurse initially assesses the patients radial pulse primarily for what purpose
Establishing a baseline
What will the nurse instruct nursing assistive personal to do when measuring an adult patients radial pulse
Palpate the patients inner wrist on the thumb side with the fingertips of your two middle fingers
What is the nurses priority action if a patients radial pulse has an irregular rhythm
Assessing the patient for a pulse deficit is useful in identifying an alteration in cardiac output
Inadequate oxygenation to the body will cause the radial pulse to become
Tachycardic
Which action would best asses the effect of exercise on a patients radial pulse measurement
Measuring the patients radial pulse before and after exercise
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient
Performing moderate exercises appropriate for a patient with this kind of injury is likely to palliate the pain
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does however seem moody and a bit uncooperative. What conclusion does the nurse draw
The absence of physiological signs and symptoms is associated with chronic pain
Which observation indicates that a patients analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention.
The patient rates her current pain as 3 out of 10 on the paint rating scale
What will the nurse instruct NAP to do regarding the management of a patients pain
Let me know at lease 30 minutes before you transport her so I can administer her analgesics
A nurse is caring for a patient who has just had major abdominal surgery to respect a portion of his colon. What is the most reliable sign that the patient has significant time postoperative pain
The patient rates his pain a 7 out of 10
Which action can the nurse take to keep a patient from consciously controlling his her breathing during an assessment
Assess respiration’s after measuring the pulse so that the patient will not try to voluntarily control their breathing
On the last assessment of a patients respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patients respiratory rate
Count breaths for sixty seconds
When measuring a patients respiratory rate the nurse will count the number of completes respiratory cycles per minute. What is the definition of a respiratory cycle
The number of inspirations and expirations per minute
During the assessment of a patients respiratory rate when the second hand reaches the fifteen second mark the respiratory count is eight. What should the nurse do at this time
At eight in the first fifteen seconds, the patient has a rapid respiratory rate of more than twenty breaths per minute. The nurse should continue to count the breaths for a full sixty seconds
