a common error when taking a pulse is

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. What is a common error when taking a pulse?

A. Placing the index finger on the radial artery located on the thumb side of a patient's wrist.
B. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure.
C. Counting the pulse for 15 seconds and multiplying the number by four.
D. None of the above will cause errors.

Correct answer: C

Rationale: The correct answer is counting the pulse for 15 seconds and multiplying the number by four. To accurately assess a patient's heart rate or pulse, it is crucial to count the pulse for a full minute. Counting for only 15 seconds and then multiplying by four may result in an inaccurate heart rate calculation. This approach could miss arrhythmias or intermittent pulsations that could be vital indicators of the patient's condition. Placing the index finger on the radial artery, which is located on the thumb side of the patient's wrist, is the correct technique for taking a pulse. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure is a valid observation and not an error in itself. Therefore, the most common error in this scenario is incorrectly calculating the pulse rate by multiplying a 15-second count by four.

2. For a patient who is blood type AB, which blood product can they receive?

A. Plasma from a type B donor
B. Whole blood from a type A donor
C. Packed RBCs from a type O donor
D. All of the above

Correct answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.

3. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?

A. "Measuring temperature using the TMT is cost-effective."?
B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
C. "TMT is not recommended for measuring core body temperature in newborn infants."?
D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?

Correct answer: B

Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.

4. What is an attack using microorganisms such as bacteria or viral agents with the intent to harm others called?

A. Assimilation
B. Defense intervention
C. Bioterrorism
D. Environmental remediation

Correct answer: C

Rationale: Bioterrorism is the act of using harmful agents like bacteria or viruses with the intention to harm others. In the context of healthcare, nurses may be involved in disaster response if bioterrorism weapons affect the community. Choice A, assimilation, refers to the process of absorbing and integrating information or ideas. Choice B, defense intervention, does not specifically relate to the intentional use of microorganisms to harm others. Choice D, environmental remediation, involves the process of cleaning up pollution or contamination in the environment, which is unrelated to the deliberate use of pathogens for harmful purposes.

5. Which of the following is part of client teaching regarding antiembolism stockings?

A. Instruct the client to roll the top portion of the stocking down if it is too long
B. Stockings are applied with the toes uncovered at the end
C. Measure for thigh-high stockings from the foot to the knee
D. Stockings are to be smooth from end to end without wrinkles

Correct answer: D

Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.