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

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

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

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. When educating a client about their new prescription for warfarin, what should the nurse advise?

Correct answer: B

Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.

3. When considering the structural organization of the human body, what is the basic unit of life?

Correct answer: D

Rationale: The basic unit of life is the cell. Cells are considered the fundamental unit of life because they are capable of carrying out all the processes necessary for life, such as growth, reproduction, responding to stimuli, and more. While chemicals, atoms, and molecules are essential components of cells and living organisms, they are not considered the basic unit of life. Chemicals are general substances, atoms are the smallest units of matter, and molecules are combinations of atoms. Therefore, the correct answer is cells, as they are the building blocks of all living organisms.

4. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

Correct answer: D

Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.

5. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?

Correct answer: D

Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive. Choice A is incorrect as health care providers are recognizing the value of self-treatment. Choice B is incorrect because self-treatment can be effective in many cases. Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.

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