Podcast
Questions and Answers
What is the primary purpose of initially assessing an apical pulse?
What is the primary purpose of initially assessing an apical pulse?
- Assessment of the patient’s cardiac function
- Establishment of a baseline as part of the patient’s vital signs (correct)
- Assessment of the patient’s risk for cardiovascular disease
- Determination of oxygen saturation
What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient’s apical pulse?
What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient’s apical pulse?
- Document the patient’s pulse rate and rhythm.
- Place the patient in the right lateral position before measuring the apical pulse.
- Review the patient’s previous apical pulse measurements.
- Place your stethoscope at the fifth intercostal space over the left midclavicular line. (correct)
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
- Reassess the pulse for 1 full minute. (correct)
- Assess the patient’s peripheral pulses.
- Wait 5 minutes, and then reassess the apical pulse.
- Review documentation regarding an irregular rhythm.
Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?
Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?
The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?
The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?
What is the major health problem resulting from a pulse deficit?
What is the major health problem resulting from a pulse deficit?
What should the nurse do when a pulse deficit is suspected?
What should the nurse do when a pulse deficit is suspected?
Which action should the nurse perform after identifying a pulse deficit?
Which action should the nurse perform after identifying a pulse deficit?
You have the following information:
Oral temperature–36.8°C.
Radial Pulse–112 weak, thready
Apical pulse–117 regular
Respirations–24 regular
Blood Pressure–104/56 right arm
–102/50 left arm
What is the pulse deficit?
You have the following information: Oral temperature–36.8°C. Radial Pulse–112 weak, thready Apical pulse–117 regular Respirations–24 regular Blood Pressure–104/56 right arm –102/50 left arm
What is the pulse deficit?
Which of the following is an early manifestation of decreased cardiac output?
Which of the following is an early manifestation of decreased cardiac output?
During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?
During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?
What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?
What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
Inadequate oxygenation to the body will cause the radial pulse to become:
Inadequate oxygenation to the body will cause the radial pulse to become:
Which action would best assess the effect of exercise on a patient’s radial pulse measurement?
Which action would best assess the effect of exercise on a patient’s radial pulse measurement?
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain?
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain?
Which observation indicates that a patient’s analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?
Which observation indicates that a patient’s analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient?
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient?
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?
The nurse is planning to measure a patient’s blood pressure. What does the systolic measurement represent?
The nurse is planning to measure a patient’s blood pressure. What does the systolic measurement represent?
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP’s last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings?
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP’s last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings?
What should the nurse do if the patient’s blood pressure is not within normal limits?
What should the nurse do if the patient’s blood pressure is not within normal limits?
What would the nurse do to prevent the spread of infection when assessing a patient’s blood pressure?
What would the nurse do to prevent the spread of infection when assessing a patient’s blood pressure?
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take?
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take?
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
Which of the following is contraindicated with taking a rectal temperature measurement?
Which of the following is contraindicated with taking a rectal temperature measurement?
Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6°F?
Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6°F?
Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment?
Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment?
Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?
Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
On the last assessment of a patient’s respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?
On the last assessment of a patient’s respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?
When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?
When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
Which of the following is a risk factor for decreased oxygen saturation level in a patient?
Which of the following is a risk factor for decreased oxygen saturation level in a patient?
What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient’s oxygen saturation level?
What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient’s oxygen saturation level?
The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?
The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?
The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement?
The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement?
A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits?
A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits?
The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?
The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?
What would cause the nurse to delay the assessment of a patient’s blood pressure?
What would cause the nurse to delay the assessment of a patient’s blood pressure?
The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?
The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?
The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?
The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?
Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?
Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?
Study Notes
Assessment of Apical Pulse
- Assessing the apical pulse helps determine the heart's rhythm and rate more accurately.
- Instruct nursing assistive personnel (NAP) to palpate the apical pulse using a stethoscope at the left fifth intercostal space.
- If the apical pulse is irregular, priority actions include conducting a more thorough assessment, possibly including an ECG.
- Communicating any changes in apical pulse rate is essential as it can indicate underlying health issues.
Evaluating Effects on Apical Pulse
- To assess the effect of crying on the apical pulse, observe heart rate before and after the episode.
- A major concern from a pulse deficit is decreased cardiac output, which can lead to inadequate tissue perfusion.
- Suspected pulse deficits require taking both apical and radial pulse measurements simultaneously.
- After confirming a pulse deficit, document findings and report any significant changes to the healthcare team.
Vital Signs Measurement
- Pulse deficit calculation: Subtract the radial pulse from the apical pulse (117 - 112 = 5).
- Early signs of decreased cardiac output may include changes in blood pressure or mental status.
- Radial pulse assessment during admissions primarily identifies overall cardiovascular status.
- Nurses instruct NAPs to measure the radial pulse for one full minute for accuracy.
- If irregular rhythms are detected in the radial pulse, reassessment and further evaluation are necessary.
Pain Assessment Post-Surgery
- The most reliable sign of significant postoperative pain is the patient's self-report of discomfort.
- NAPs should be instructed to regularly assess and report the patient's pain levels per protocol.
- Effective pain management is indicated by a patient expressing a lower pain rating after intervention.
Patient Behavior and Pain Perception
- A patient showing lack of typical discomfort signs may still experience pain; a nuanced assessment is needed.
- Systolic blood pressure measures the pressure in arteries during heartbeats, indicating heart function.
- New NAPs may produce inaccurate blood pressure readings due to lack of experience with correct techniques.
Blood Pressure Measurement Protocol
- If blood pressure readings are abnormal, further assessment and intervention are warranted.
- Use proper infection control techniques when conducting blood pressure assessments.
- If discrepancies in NAP blood pressure readings occur, reassessment by an experienced professional is necessary.
Temperature Assessment Techniques
- When measuring rectal temperature, NAPs should ensure proper lubrication and position.
- Certain conditions contraindicate rectal temperature measurement, such as rectal surgery.
- Evaluating antipyretic effectiveness involves rechecking the body temperature after administration.
Respiratory Rate Assessment
- A respiratory cycle consists of one inhale and one exhale.
- If the respiratory count reaches 8 at the 15-second mark, the nurse must multiply by four for the total breaths per minute.
- To minimize exercise effects on respiratory rates, allow the patient to rest before assessment.
Oxygen Saturation Considerations
- Risk factors for decreased oxygen saturation include respiratory disease, obesity, or smoking history.
- NAPs are educated on choosing appropriate sites for measuring oxygen saturation, avoiding areas with poor circulation.
- Initial actions for low oxygen saturation (e.g., 83%) include positioning the patient in a high-fowler's position and providing supplemental oxygen.
Blood Pressure Measurement Techniques
- High blood pressure readings may arise from improper cuff size or patient anxiety.
- Delay blood pressure assessment if the patient has recently engaged in physical activity to avoid inaccurate readings.
- Multiple blood pressure measurements aim to account for variability and ensure accuracy.
Lifestyle Modifications for Blood Pressure Management
- Patients should receive education on maintaining a heart-healthy diet and engaging in regular physical activity to lower blood pressure.
- Blood pressure should be measured on the arm opposite a mastectomy to ensure accuracy and patient safety.
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Description
Clinical Skills: Assessing Apical Pulse Assessing Apical-Radial Pulse Assessing Radial Pulse Assessing Pain Obtaining Blood Pressure by the One-Step Method Taking Temperatures Assessing Respiration: Rate, Rhythm, and Effort Measuring Oxygen Saturation with Pulse Oximetry Obtaining Blood Pressure by the Two-Step Method
