A patient is taking medications to treat a heart arrhythmia. Which site should be used to assess pulse in this patient?

Correct Answer: D

Rationale: Arrhythmias disrupt peripheral pulse reliability, requiring a central site. Brachial and radial are peripheral, potentially missing beats. Dorsalis pedis is distal, less accurate for arrhythmias. Apical at the heart apex directly counts beats, unaffected by peripheral irregularities, making it correct. Choice D is standard for arrhythmia patients, ensuring accurate rate and rhythm assessment per cardiovascular nursing protocols.

Correct Answer: B

Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.

Correct Answer: C

Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.

Correct Answer: D

Rationale: In the context of vital signs assessment for nurses, the correct answer is D) Assessing changes in body temperature, which cannot be delegated to nursing assistive personnel. Assessing changes in body temperature requires critical thinking, clinical reasoning, and the ability to interpret the significance of temperature fluctuations in relation to the patient's overall condition. This task falls under the scope of the licensed nurse's responsibility as it involves making clinical judgments and decisions based on the assessment data gathered, which is beyond the scope of practice for nursing assistive personnel. Option A) Selecting appropriate route and device can be delegated as it involves following a standardized procedure and does not require clinical judgment. Option B) Obtaining temperature measurement at ordered frequency can also be delegated as it involves a routine task that can be performed by nursing assistive personnel under the supervision of a nurse. Option C) Being aware of the usual values for the patient is important for nursing assistive personnel to know as part of their role in collecting accurate data, but it does not involve interpreting the significance of changes in body temperature, which requires a higher level of clinical knowledge. In an educational context, understanding the delegation of tasks in the healthcare setting is crucial for maintaining patient safety and ensuring that each member of the healthcare team is working within their scope of practice. Nurses must be able to differentiate between tasks that can be delegated and those that require their expertise to make informed clinical decisions. This question highlights the importance of clear communication, delegation, and the nurse's role in assessing and interpreting vital signs data to provide safe and effective patient care.

Correct Answer: C

Rationale: In this scenario, option C is the correct choice because documenting that the medication was not given due to low blood pressure is crucial for patient safety and effective communication among the healthcare team. By documenting this information, the nurse ensures that the patient receives appropriate care and that other healthcare providers are aware of the rationale behind withholding the medication, which can prevent potential adverse events. Option A is incorrect because withholding important information from the patient goes against the principles of patient-centered care and informed decision-making. Patients have the right to be informed about their health status and treatment decisions. Option B is inadequate because simply documenting the blood pressure without indicating the reason for not giving the medication fails to provide a complete picture of the situation. This omission can lead to miscommunication and potential errors in the patient's care. Option D is also incorrect as it is essential for the nurse to communicate with the healthcare provider about why the medication was held. This ensures that the provider is aware of the patient's condition and can make necessary adjustments to the treatment plan. Educationally, this scenario highlights the importance of accurate documentation, effective communication, and adherence to medication administration protocols based on specific patient parameters. It underscores the critical role of nurses in advocating for patient safety and collaborating with the healthcare team to deliver quality care.