Pulse Sherpath Review

Which solution would the nurse consider for a patient with bradycardia? Suggest activities to increase the heart rate. Administer medications to slow the heart rate. Encourage measures to stabilize heart rhythm. Document patient's pulse rate alteration will resolve.

Suggest activities to increase the heart rate. Suggesting activities to increase the heart rate is a solution for a patient who has bradycardia (slowed pulse rate).

Which explanation would the nurse make when discussing a patient's cardiac output? The number of heartbeats in 1 minute The amount of blood the heart pumps per minute The amount of time it takes for one cardiac cycle The number of pulse sites that are palpable

The amount of blood the heart pumps per minute The amount of blood the heart pumps in 1 minute is the cardiac output, which can cause problems if the heart rate is too fast or too slow.

Which actions would a nurse take for a patient who has tachycardia from low fluid volume? Select all that apply. A) Administer prescribed fluid replacement. B) Administer diuretic medication. C) Administer prescribed oxygen. D) Prepare the patient for an emergency pacemaker insertion. E) Prepare the patient for an electrocardiogram.

A) Administer prescribed fluid replacement. The nurse would administer prescribed fluid replacement to replenish lost fluid. C) Administer prescribed oxygen. The nurse would administer oxygen to increase the oxygen levels. E) Prepare the patient for an electrocardiogram. The nurse would prepare the patient for an electrocardiogram to determine the specific rhythm occurring.

Which factors would the nurse consider when the patient's pulse rate is decreased? Select all that apply. A) Age B) Stress C) Hypoxia D) Hypovolemia E) Hypothyroidism

A) Age E) Hypothyroidism Stress, Hypoxia, and hypovolemia would increase the heart rate

Which action would the nurse take after obtaining a patient's regular radial pulse rate of 45 in 30 seconds? A) Document the appropriate heart rate. B) Take the radial pulse for 1 full minute. C) Find the point of maximal impulse. D) Notify the health care provider immediately.

A) Document the appropriate heart rate. The nurse would document the appropriate heart rate (45 × 2 = 90) because the patient's pulse is regular.

Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? Select all that apply. A) Hypothermia B) Beta-blocker administration C) Increased intracranial pressure D) Hyperthyroidism E) Overexertion

A) Hypothermia B) Beta-blocker administration C) Increased intracranial pressure Increased intracranial pressure lowers the heart rate; thus the nurse would consider a hypothesis of Bradycardia.

Which actions would the nurse perform to obtain patient observation cues for pulse? Select all that apply. A) Interview the patient B) Check laboratory results for the patient's calcium level C) Visually inspect the patient for alterations D) Review the patient's baseline on the graphic/flow sheet E) Read the nurse's notes about the patient's pulse

A) Interview the patient Interviewing the patient is a method to collect patient observation cues. C) Visually inspect the patient for alterations visually inspecting the patient for alterations is a method to collect patient observation cues

Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase? Select all that apply. A) Notify health care provider. B) Assist with electrical cardioversion. C) Transfer to intensive care unit. D) Prepare to insert an emergency pacemaker. E) Suggest a consult with a cardiologist. F) Initiate cardiopulmonary resuscitation (CPR).

A) Notify health care provider B) Assist with electrical cardioversion. C) Transfer to the intensive care unit. E) Suggest a consult with a cardiologist Attention: Prepare to insert an emergency pacemaker. Bradycardia (not tachycardia) can lead to an emergency pacemaker.

Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure? Select all that apply. A) Pain B) Older age C) Fever D) Exercise E) A drop in blood pressure

A) Pain C) Fever E) A drop in blood pressure

Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate? A) Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. B) Patient will maintain capillary refill to fingers/toes, skin color, skin integrity, and skin temperature of extremities at the 2-week follow-up appointment. C) Patient will maintain adequate fluid volume within 8 hours. D) Patient will exhibit good tissue perfusion.

A) Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions . This is an expected outcome because it is measurable, specific, attainable, and realistic, and has a timeline that is short term.

Which actions would the nurse take when the nurse finds the following pulse rates on the flow sheet: 86, 94, 100, 105, 110? Select all that apply. A) Reassess cardiac system. B) Perform a head-to-toe assessment. C) Review medications. D) Notify the health care provider. E) Monitor heart rate every 4 hours. F) Review electrolyte levels.

A) Reassess cardiac system. B) Perform a head-to-toe assessment. C) Review medications. D) Notify the health care provider. F) Review electrolyte levels.

Which conditions would be likely to cause tachycardia? Select all that apply. Beta blocker medication Sleep Anemia Bronchodilator medication Drop in blood pressure Athletic fitness level

Anemia Anemia, a lack of red blood cells, is a cause of tachycardia. Bronchodilator medication Bronchodilator medication, a respiratory medication, is a cause of tachycardia. Drop in blood pressure A decrease or drop in blood pressure is a cause of tachycardia

Which pulse site would the nurse use that is the most definitive site to determine a patient's cardiac health? Apical Radial Peripheral Carotid

Apical (corect answer) The apical pulse is a central pulse that can be auscultated over the apex of the heart, the most definitive site used for cardiac health. Radial Although the radial is the site most often used for vital signs, it is not the most definitive for cardiac health. Peripheral Although peripheral sites can be used to assess a pulse, they are located in arteries away from the heart. Carotid The carotid is in the neck and is a peripheral pulse, not a definitive site to determine a patient's cardiac health.

Which patient pulse rates would the nurse report as unexpected (abnormal)? Select all that apply. A) 150 for a newborn B) 52 for an older adult C) 90 for a 6-year-old D) 110 for a 15-year-old E) 180 for a 1-year-old

B) 52 for an older adult 52 is unexpected for an older adult; expected is 60 to 100. D) 110 for a 15-year-old 110 for a 15-year-old is unexpected; expected is 50 to 90. E) 180 for a 1-year-old 180 for a 1-year-old is unexpected regardless of whether the 1-year-old is awake (80 to 150) or asleep (70 to 120).

In which patient instances would the nurse use a Doppler unit to assess pulse? Select all that apply. A) 34-year-old patient with an irregular heart rhythm B) 56-year-old morbidly obese patient with hardening of the arteries C) 45-year-old patient with intestinal problems D) 62-year-old patient with obstructed blood vessels in the feet E) 26-year-old patient with poor circulation in the lower extremities

B) 56-year-old morbidly obese patient with hardening of the arteries D) 62-year-old patient with obstructed blood vessels in the feet E) 26-year-old patient with poor circulation in the lower extremities

Which hypothesis would the nurse develop for an adult patient who has a pulse rate of 40 and is sluggish and confused? A) Tachycardia B) Bradycardia C) Risk for Bradycardia D) Heart Rate Within Normal Limits

B) Bradycardia

Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? Select all that apply. A) Encourage oral fluid intake. B) Elevate legs when at rest. C) Check peripheral pulses. D) Balance periods of rest and exercise. E) Assess heart sounds.

B) Elevate legs when at rest. When edema is present, legs are elevated to decrease swelling. C) Check peripheral pulses. Peripheral pulses are checked to determine perfusion to the extremities. D) Balance periods of rest and exercise. Balancing periods of rest and exercise enhance activity measures and cardiac output E) Assess heart sounds. The nurse assesses heart sounds to determine functioning of the cardiac system.

In which instances would the nurse listen to an apical pulse? Select all that apply. A) If the patient has a palpable peripheral pulse B) If the patient has weak heart contractions C) When the patient's pedal pulse is difficult to palpate D) When the patient's radial pulse is 86 and irregular E) When a medication may alter the patient's cardiac function

B) If the patient has weak heart contractions If the patient has weak heart contractions, the nurse may have difficulty palpating the pulse, and listening to the apical pulse would allow an accurate assessment. D) When the patient's radial pulse is 86 and irregular In the presence of an irregular rhythm, it may be easier for the nurse to auscultate heart sounds and count the apical pulse. E) When a medication may alter the patient's cardiac function When a medication regimen may alter cardiac function, it is imperative that the nurse auscultate the apical pulse.

At which site would the nurse assess the patient's apical pulse? A) Thumb side of the wrist B) Left fifth and sixth intercostal space C) Right midclavicular line D) Simultaneously on both sides of the neck

B) Left fifth and sixth intercostal space Assessment of the apical pulse requires use of a stethoscope and is best heard between the left fifth and sixth intercostal spaces, over the midclavicular line.

Which adult patient would the nurse assess first? A) One with heart disease B) One with tachycardia C) One with stable breathing D) One with patent (open) airway

B) One with tachycardia Tachycardia, if severe, can be life-threatening and is an acute condition that would be assessed first.

Which treatment option would the nurse anticipate for a patient with bradycardia whose pulse continues to decrease? A) Discontinue continuous monitoring. B) Prepare the patient for an emergency pacemaker. C) Transfer patient to a long-term care facility. D) Consult a physical therapist.

B) Prepare the patient for an emergency pacemaker. If the patient with bradycardia has a pulse that continues to decrease, the patient is declining and would require an emergency pacemaker

Which cues would the nurse assess for in an adult patient with bradycardia? Select all that apply. A) Pulse rate 125 B) Sluggish C) Lethargic D) Confused e) Bronchodilator prescription

B) Sluggish A patient with bradycardia will be sluggish because of a lack of oxygen to the brain. C) Lethargic A patient with bradycardia will be lethargic because of a lack of oxygen to the tissue. D) Confused A patient with bradycardia will be confused because of a lack of oxygen to the brain.

Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells? A) This test will monitor your heart rate and rhythm just during sleep. B) This test utilizes a portable device attached to the chest by electrodes. C) It is an implantable device that is surgically inserted under the skin to continuously monitor the heart's activity. D) It is a device intended to convert life-threatening arrhythmias of the heart to normal sinus rhythm.

B) This test utilizes a portable device attached to the chest by electrodes. A Holter monitor utilizes a portable device attached to the chest by electrodes. It measures and records the heart's electrical activity continually.

Which pulse site would the nurse check when an infant appears lifeless? A) Carotid B) Femoral C) Brachial D) Popliteal

C) Brachial The brachial pulse in the arm is the best choice as it is easily accessible on an infant.

Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? Select all that apply. A) Raise the head of the bed. B) Slowly ambulate the patient. C) Offer noncaffeinated beverages. D) Administer fluid replacement. E) Monitor potassium and calcium levels.

C) Offer non-caffeinated beverages. D) Administer fluid replacement. E) Monitor potassium and calcium levels.

Which finding would the nurse observe in an adult patient with Bradycardia who is improving? A) Pulse rate increases to 110. B) Pulse rate decreases from 60 to 50. C) Reflexes increase. D) Responses decrease.

C) Reflexes increase. Reflexes increasing indicates the patient is improving because slowed reflexes are a cue for Bradycardia.

Which action would the nurse take to obtain a patient's apical pulse? A) Place a cooled stethoscope on the chest. B) Turn the patient to the right side. C) Listen at the angle of Louis. D) Count "lub-dub" as one beat.

D) Count "lub-dub" as one beat

Which questions would the nurse ask a patient before performing a pulse assessment? Select all that apply. Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath? Have you engaged in any type of exercise in the past 90 minutes?

Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath?

Which factors can affect a patient's heartbeat? Select all that apply. Fever Hunger Exercise Medications Hypovolemia

Fever Fever causes the heart rate to be elevated because of an increased metabolic rate. Exercise Exercise may increase the heart rate while someone is actively participating in an activity. Medications Medications may increase or decrease a patient's heart rate. Hypovolemia A low fluid volume status may cause the heart to pump faster because of the lower blood volume and stimulation of the sympathetic nervous system.

Match the expected pulse parameters with the appropriate age group. Newborn (awake or asleep) 6-year-old 15-year-old Adult 60-100 80-180 50-90 75-110

Newborn (awake or asleep) 80-180 (100 - 180)-awake (80-160)-asleep 6-year-old 75-110 15-year-old 50-90 Adult 60-100