Term
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will
a) Decrease the blood glucose
b) Decrease the respiratory rate
c) Decrease the apical pulse
d) Decrease the blood volume |
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Definition
Decrease the apical pulse
Explanation:
Certain cardiac medications, such as digoxin, decrease the heart rate.
Reference:
Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 524. |
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Term
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
a) The oxygen levels in the blood
b) The volume of air entering the lungs
c) The ability of the arteries to stretch
d) The thickness of circulating blood |
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Definition
The ability of the arteries to stretch
Explanation:
Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs. (less)
Reference:
Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 530-531. |
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Term
What is the pulse pressure of a patient whose blood pressure is 132/82 mm Hg?
a) 214
b) 1.6
c) 50
d) 100 |
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Definition
50
Explanation:
Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction. The numerator is the systolic pressure; the denominator is the diastolic pressure. The difference between the two is called the pulse pressure. (less)
Reference:
Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 530. |
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Term
A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?
a) Apnea
b) Hyperventilation
c) Hypoventilation
d) Dyspnea |
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Definition
Dyspnea
Explanation:
Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than 4 to 6 minutes. (less)
Reference:
Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 530. |
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Term
When assessing a patient's vital signs, a nursing student has explained each of her next actions prior to assessing the patient's temperature, pulse, and blood pressure, but has not announced her intention to assess the patient's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?
a) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
b) The nurse likely assessed the patient's respiratory rate simultaneous to heart rate.
c) Tachypnea is an expected finding among hospitalized individuals.
d) Respirations have both autonomic and voluntary control. |
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Definition
Respirations have both autonomic and voluntary control.
Explanation:
Because respiratory rate is under both autonomic and voluntary control, making the patient conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate and tachypnea is not an expected finding. (less) |
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Term
Which peripheral pulse site is generally used in emergency situations?
a) Carotid
b) Apical
c) Radial
d) Temporal |
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Definition
Carotid
Explanation:
The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a patient in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. (less)
Reference:
Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 527. |
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