which technique is correct when the nurse is assessing the radial pulse of a patient

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Which technique is correct when assessing the radial pulse of a patient?

A. Palpate for 1 minute if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

2. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?

A. Germ theory
B. Naturalistic theory
C. Magicoreligious theory
D. Biomedical or scientific theory

Correct answer: B

Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.

3. Which of the following is an example of physical abuse?

A. A slap to the person's hand
B. Threatening the person
C. Ignoring and isolating a person
D. Leaving a patient soiled for hours

Correct answer: A

Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.

4. Which of the following descriptions best describes the function of the thyroid gland?

A. The thyroid gland converts glucose into glycogen
B. The thyroid gland secretes cortisol during times of stress
C. The thyroid gland regulates body metabolism
D. The thyroid gland affects skin pigmentation

Correct answer: C

Rationale: The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyronine (T3), which work to regulate the metabolism of the body's cells. The primary function of the thyroid gland is to control the body's metabolic rate, affecting processes such as heart rate, temperature regulation, and energy levels. Choices A, B, and D are incorrect because the thyroid gland is not involved in converting glucose into glycogen, secreting cortisol, or affecting skin pigmentation. Instead, the primary role of the thyroid gland is to regulate the metabolism and energy balance in the body.

5. When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)

A. Increased pulse rate, normal EKG
B. Decreased pulse rate, abnormal EKG
C. Tachycardia, poor EKG graph
D. Bradycardia, poor EKG graph

Correct answer: C

Rationale: When a patient laughs due to anxiety during an EKG, it is likely to cause tachycardia, which is a rapid heart rate. This increased heart rate can lead to poor EKG graph quality as the electrical signals from large moving muscles can interfere with data collection from the chest leads. Therefore, in this scenario, the EKG is expected to show tachycardia with poor graph quality. Choices A, B, and D are incorrect because a patient laughing out of anxiety is more likely to result in an increased pulse rate (tachycardia) rather than a decreased pulse rate (bradycardia) or a normal EKG.