Fundamentals Module 1 Lesson 3 Quiz
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) A) A newborn B) A patient returning from OR after having a hip replacement C) A patient who received morphine for severe cancer pain D) A student who is getting ready to take a final exam E) A patient who had bleeding episode
B) A patient returning from OR after having a hip replacement C) A patient who received morphine for severe cancer pain Having general anesthesia or receiving an opioid analgesic may decrease the pulse rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the heart attempts to compensate to maintain cardiac output.
Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A) a 76-year-old with Type 1 diabetes who is otherwise healthy. B) A patient who was just informed of a diagnosis of cancer. C) A patient with peripheral vascular disease. D) A patient who is receiving bolus IV fluids E) A patient with Alzheimer's Disease
B) A patient who was just informed of a diagnosis of cancer. C) A patient with peripheral vascular disease. Correct D) A patient who is receiving bolus IV fluids Certain conditions place patients at risk for pulse alterations. This may include a person with cardiovascular disease, a patient who is experiencing anxiety, and a patient who received a sudden infusion of IV fluids. Uncomplicated diabetes and Alzheimer's disease fail to directly relate to pulse alteration.
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) A) An apical pulse of a patient who is going to receive digoxin (Lanoxin). B) A radial pulse on a patient with a 1200 mL fluid restriction. C) A radial pulse of a patient in the emergency room with chest pain. D) A femoral pulse following a lower leg amputation. E) The Temporal pulse of a child
B) A radial pulse on a patient with a 1200 mL fluid restriction. E) The temporal pulse of a child The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site.
Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should consider: A) Checking the carotid pulse B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate C) Counting the pulse again for 30 seconds and multiplying the results by two D) Checking the radial pulse on the opposite side
B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate. The nurse should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. The pulse on the opposite side should also be assessed to see if the alteration is happening bilaterally, in addition to assessing the apical pulse.
What is the normal pulse range for an adult? A) 120-160 beats per minute B) 90-140 beats per minute C) 60-100 beats per minute D) 50-80 beats per minute
C) 60-100 beats per minute The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute.
The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. T/F
FALSE For routine auscultation of the apical pulse, you should rely on the diaphragm side of the chest piece because it is designed to pick up higher-pitched heart sounds like that of the apical pulse.The bell side of the stethoscope should be used to assess heart sounds to identify murmurs.
