Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical/radial pulse indicates that the two values differ significantly, a finding that suggests which of the following health problems? - Answer- Peripheral vascular disease Explanation: A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does not signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD. Which peripheral pulse site is generally used in emergency situations? - AnswerCarotid 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 A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which of the following actions should the nurse perform in order to obtain the accurate temperature of the client? - Answer- Wait for 15 to 20 minutes before measuring the oral temperature Explanation: The nurse should wait for 15 to 20 minutes and then measure the oral temperature of the client because hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation and not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site because temperature may reflect the temperature of the water used during sponging. Friction used to dry the skin may also influence the temperature. The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? - Answer- 40% of the circumference of the limb to be used Explanation: The width of the cuff should be about 40% of the circumference of the limb to be used. A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? - Answer- There is an auscultatory gap Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique. A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child? - Answer- Perform the blood pressure measurement last. Explanation: The blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and prevent obtaining the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely call more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety. The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart? - Answer- Listen for heart sounds. Explanation: The apex of the heart is found after palpating between the fifth and sixth ribs, then moving the stethoscope the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lub-dub" sound counts as one beat. A nurse is assessing the respiratory rate of a sleeping infant. Which of the following would the nurse document as a normal finding? - Answer- 30 to 60 breaths per minute Explanation: When assessing the respiratory rate of an infant, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths per minute. The normal respiratory rate of an adult is 12 to 20 breaths per minute. A respiratory rate of 60 to 80 breaths per minute or 80 to 100 breaths per minute is abnormal and is not seen in infants or adults when they are at rest. Tachypnea is an abnormally fast respiratory rate, usually above 20 breaths per minute in the adult, whereas bradypnea is an abnormally slow respiratory rate, usually less than 12 breaths per minute in the adult. What is the pulse pressure of a patient whose blood pressure is 132/82 mm Hg? - Answer- 50 Explanation: