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. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?

A. This too shall pass.
B. Take the child immediately to the ER
C. Contact the Poison Control Center quickly
D. Give the child syrup of ipecac

Correct answer: C

Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.

3. Over a patient's lifespan, how does the pulse rate change?

A. starts out fast and decreases as the patient ages.
B. starts out slower and increases as the patient ages.
C. varies from slow to fast throughout the lifespan.
D. stays consistent from birth to death.

Correct answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

4. Patients have a right to ______________.

A. only enough information so they can comply with care
B. ALL of their health-related information
C. small amounts of information so they do not get nervous
D. moderate amounts of information unless they are old

Correct answer: B

Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.

5. Which of the following is the correct sequence for removing personal protective equipment?

A. Remove gown, gloves, shoe covers, mask
B. Remove mask, gloves, gown, shoe covers
C. Remove gloves, gown, mask, shoe covers
D. Remove shoe covers, mask, gloves, gown

Correct answer: C

Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.