Sherpath: Pulse WK3

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Which site is the natural pacemaker of the heart?

Sinoatrial Node (correct)

Atrioventricular node

Purkinje fibers

Internodal pathway

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 (correct)

The amount of time it takes for one cardiac cycle

The number of pulse sites that are palpable

Which pulse site would the nurse use that is the most definitive site to determine a patient’s cardiac health?

Apical (correct)

Radial

Peripheral

Carotid

Which factors can affect a patient’s heartbeat? (Select all that apply.)

Fever Signup and view all the answers

Which questions would the nurse ask a patient before performing a pulse assessment? (Select all that apply.)

Do you smoke? Signup and view all the answers

In which instances would the nurse listen to an apical pulse? (Select all that apply.)

If the patient has weak heart contractions Signup and view all the answers

Match the pulse site with its location.

Either side of the neck = Carotid Either side of the forehead = Temporal Inner aspect of the arm = Brachial Inside the wrist = Radial Signup and view all the answers

Match the expected pulse parameters with the appropriate age group.

Newborn (awake or asleep) = 80-100 6 y/o = 75-110 15 y/o = 50-90 Adult = 60-100 Signup and view all the answers

Which conditions would be likely to cause tachycardia? (Select all that apply.)

anemia Signup and view all the answers

Which actions would the nurse perform to obtain patient observation cues for pulse? (Select all that apply.)

Interview the patient Signup and view all the answers

Which hypothesis would the nurse develop for an adult patient who has a pulse rate of 40 and is sluggish and confused?

Bradycardia Signup and view all the answers

Which adult patient would the nurse assess first?

One with tachycardia Signup and view all the answers

Which solution would the nurse consider for a patient with bradycardia?

Suggest activities to increase the heart rate. Signup and view all the answers

Which actions would a nurse take for a patient who has tachycardia from low fluid volume? (Select all that apply.)

Administer prescribed fluid replacement. Signup and view all the answers

Which treatment option would the nurse anticipate for a patient with bradycardia whose pulse continues to decrease?

Prepare patient for an emergency pacemaker. Signup and view all the answers

Match the measure to its nursing intervention.

Teach patient to move extremities periodically = Tissue perfusion Encourage oral intake = Fluid volume Assess heart sounds = Cardiac output Balance periods of rest and exercise = Activity Signup and view all the answers

List the electrical impulse for the conduction cycle in the heart, beginning with the natural pacemaker.(number the order)

(4)Bundle of His (6)Purkinje fibers (2)Internodal pathway (1)Sinoatrial node (3)Atrioventricular node (5)Right and left bundle branches Signup and view all the answers

Match the numeric value the nurse would document for each pulse description.

Normal pulse, able to palpate with normal pressure = 2+ Bounding pulse, may be able to see pulsation = 3+ Weak and thready, difficult to palpate = 1+ Absent pulse = 0 Signup and view all the answers

Which factors would the nurse consider when the patient’s pulse rate is decreased? (Select all that apply.)

Age Signup and view all the answers

At which site would the nurse assess the patient’s apical pulse?

Left fifth and sixth intercostal space Signup and view all the answers

Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? (Select all that apply.)

Offer noncaffeinated beverages. Signup and view all the answers

Which action would the nurse take after obtaining a patient’s regular radial pulse rate of 45 in 30 seconds?

Document the appropriate heart rate. Signup and view all the answers

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.)

Pain Signup and view all the answers

Match the pulse site to when each site is assessed by the nurse.

To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest = Carotid To measure blood pressure = Brachial To determine discrepancies with radial pulse = Apical To assess circulation to the foot = Dorsalis Pedis Signup and view all the answers

Which action would the nurse take to obtain a patient’s apical pulse?

Count “lub-dub” as one beat. Signup and view all the answers

Which patient pulse rates would the nurse report as unexpected (abnormal)? (Select all that apply.)

52 for an older adult Signup and view all the answers

Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate?

Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. Signup and view all the answers

Which pulse site would the nurse check when an infant appears lifeless?

Brachial Signup and view all the answers

In which patient instances would the nurse use a Doppler unit to assess pulse? Select all that apply.

56-year-old morbidly obese patient with hardening of the arteries Signup and view all the answers

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. Signup and view all the answers

What heart rate would the nurse record for a patient’s heart rate of 46 beats in 30 seconds? _____ beats/min

92 Signup and view all the answers

Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells?

This test utilizes a portable device attached to the chest by electrodes. Signup and view all the answers

Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? (Select all that apply.)

Hypothermia Signup and view all the answers

Which cues would the nurse assess for in an adult patient with bradycardia? (Select all that apply.)

Sluggish Signup and view all the answers

Which finding would the nurse observe in an adult patient with Bradycardia who is improving?

Reflexes increase. Signup and view all the answers

Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? Select all that apply.

Elevate legs when at rest. Signup and view all the answers

Match the pulse site the nurse would use to assess each pulse.

Medial surface of both ankles = Posterior tibial Behind both knees = popliteal On top of both feet = pedal By the groin on both sides = femoral Signup and view all the answers

Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase? Select all that apply.

Notify health care provider. Signup and view all the answers

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.

(1)Older adult patient with no respirations (3)Older adult patient with chronic heart disease (4)Middle-aged patient with a heart rate of 65 (2)Adult patient with heart rate of 180 Signup and view all the answers