Chapter 12: Vital Signs - Nurselytic

Questions 30

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Chapter 12 : Vital Signs Questions

Question 1 of 5

A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?

Correct Answer: C

Rationale: A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

Question 2 of 5

A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?

Correct Answer: A

Rationale: A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

Question 3 of 5

A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

Correct Answer: B

Rationale: A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

Question 4 of 5

A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?

Correct Answer: D

Rationale: A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied.

Question 5 of 5

When instructing a primary caregiver about keeping a daily log of blood pressure readings what instructions should the nurse include?

Correct Answer: B,E

Rationale: Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 in above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes.

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