VNSG 1323: Chapter 12 Prep U Questions || with 100% Error-free Answers.
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Module
VNSG 1323:
Institution
VNSG 1323:
A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? correct answers Listen with the stethoscope at the fifth intercostal space left mid-clavicular line.
Explanation: To assess the apical pulse, the nurse places the stethoscope over the left vent...
VNSG 1323: Chapter 12 Prep U Questions || with 100%
Error-free Answers.
A nurse can most accurately assess a client's heart rate and rhythm by which of the following
methods? correct answers Listen with the stethoscope at the fifth intercostal space left mid-
clavicular line.
Explanation: To assess the apical pulse, the nurse places the stethoscope over the left ventricle.
The stethoscope is placed at the level of the fifth intercostal space left mid-clavicular line.
The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client
to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?
correct answers Immediately assist the client back to bed.
Explanation: If a client becomes severely symptomatic while standing for a blood pressure
measurement, the nurse should immediately help the client back to bed without completing the
measurement. The client's safety is the priority. Asking the client to explain the term "dizzy",
checking the blood pressure, or asking the client if she wants to sit down are inappropriate. The
client's safety is the utmost concern.
A nurse records a pulse rate of 170 beats/min on a client's flow chart. For which of the following
age groups would this be considered a normal reading? correct answers Newborn
Explanation: For a newborn, a pulse rate of 80 to 180 beats/min is considered normal. A normal
rate for a child age 10 years is 75 to 110; a normal rate for an adolescent is 60 to 100; a normal
rate for an adult is 60 to 100.
The normal adult temperature obtained through the oral route ranges from: correct answers
97.6°F to 99.6°F (36.4°C to 37.6°C)
Explanation: Normal adult oral temperature ranges from 97.6°F to 99.6°F (36.4°C to 37.6°C)
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse
can anticipate that the digoxin will: correct answers Decrease the apical pulse.
Explanation: Certain cardiac medications, such as digoxin, decrease the heart rate.
Assessment of the pulse amplitude is accomplished by: correct answers Palpating the flow of
blood through an artery.
Explanation: The pulse amplitude describes the quality of the pulse in terms of its fullness, and
reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing
through an artery. Auscultation is by hearing the blood flow through an artery. Auscultation
cannot assess pulse amplitude. A nurse cannot palpate the area of the left ventricle.
, During a busy shift, Nurse R. admitted a postoperative client who is obese. Nurse R. used the
standard size of blood pressure cuff available on the unit, despite the fact that the client's upper
arms have a large circumference. What are the potential consequences of Nurse R.'s action?
correct answers Nurse R. may obtain a blood pressure reading that is higher than the actual blood
pressure.
Explanation:The "80/40" rule states that in order to obtain an accurate blood pressure
measurement, the cuff bladder length should be approximately 80% of the circumference of the
upper arm and the cuff bladder width should be optimally 40% of the circumference of the upper
arm. If a blood pressure cuff is too narrow, the reading could be erroneously high because the
pressure is not evenly transmitted to the artery. Likewise, if a blood pressure cuff is too wide, the
reading could be erroneously low. This mismatched cuff will not, however, make it particularly
difficult to inflate the cuff and brachial occlusion is not a significant risk.
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-
hour period? correct answers 1700
Explanation: Body temperature fluctuates throughout the day. Temperature is usually lowest
around 0300 and highest from 1700 to 1900.
When assessing blood pressure using a Doppler ultrasound, what technique by the nurse would
obtain the best reading? correct answers Center the bladder of the cuff over the artery, lining up
the artery marker on the cuff with the artery itself.
Explanation: Have the client assume a comfortable lying or sitting position with the appropriate
limb exposed, and center the bladder of the cuff over the artery, lining up the artery marker on
the cuff with the artery itself. If using a mercury manometer, check to see that the manometer is
in the vertical position and that the mercury is within the zero level with the gauge at eye level.
The nurse should avoid using excessive pressure when applying the Doppler probe, as this may
occlude the artery.
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 health problem? correct answers
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.
A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as
a normal finding? correct answers 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
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