What is the primary purpose of pulse assessment?

Correct Answer: C

Rationale: Pulse assessment primarily evaluates cardiac status , reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure relates but requires a cuff. Temperature isn't pulse-related. Respiratory status is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.

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: In this scenario, the correct answer is C) A patient with a fever of 39.4°C (103°F) is most at risk for tachycardia. Tachycardia is defined as an elevated heart rate, which can be a physiological response to fever. When the body temperature rises, the heart rate typically increases to help distribute heat and nutrients throughout the body. This is a normal response to fever. Option A) A healthy professional tennis player is unlikely to be at risk for tachycardia unless there are underlying health issues or external factors causing it. Exercise can increase heart rate, but in a healthy individual, it is not typically a cause for concern regarding tachycardia. Option B) A patient admitted with hypothermia would likely have a decreased heart rate (bradycardia) rather than tachycardia. Hypothermia slows down physiological processes, including heart rate, in an attempt to conserve energy and maintain core body temperature. Option D) A 90-year-old male taking beta blockers is also at risk for bradycardia rather than tachycardia. Beta blockers are medications that can lower heart rate by blocking the effects of adrenaline. In older adults, especially those with comorbidities, beta blockers can further decrease heart rate, making tachycardia less likely. In an educational context, understanding the relationship between vital signs and underlying conditions is crucial for healthcare providers to assess and manage patients effectively. By knowing the causes of tachycardia and the potential risk factors associated with it, healthcare professionals can make informed decisions regarding patient care and treatment interventions.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) 80, which represents the pulse pressure. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. In this case, 140 (systolic) - 60 (diastolic) = 80 (pulse pressure). Option A) 140 is incorrect because it represents the systolic blood pressure, not the pulse pressure. Option B) 60 is the diastolic blood pressure, not the pulse pressure. Option D) 200 is not the correct calculation for pulse pressure in this case. Educationally, understanding vital signs like blood pressure and pulse pressure is crucial for assessing a patient's cardiovascular health. Pulse pressure provides information about the force the heart generates with each contraction and the health of the arteries. A normal pulse pressure is typically around 30-40 mmHg. Deviations from this range can indicate various cardiovascular conditions, so accurate assessment and interpretation are essential for patient care.

Correct Answer: C

Rationale: In the given scenario, the correct action for the nurse to take when finding a respiratory rate of 30 breaths per minute is option C: Assess the client for signs of respiratory distress. Rationale: Assessing the client for signs of respiratory distress is the most appropriate action because a respiratory rate of 30 breaths per minute is above the normal range (typically 12-20 breaths per minute for adults). This elevated respiratory rate could indicate underlying respiratory issues or distress that need immediate attention. By assessing the client for signs of respiratory distress, the nurse can gather more information to determine the cause of the abnormal respiratory rate and initiate appropriate interventions promptly. Why the other options are incorrect: A) Documenting the respiratory rate as normal (option A) is not appropriate in this case as a rate of 30 breaths per minute is higher than the normal range. B) Initiating oxygen therapy (option B) without further assessment could be unnecessary and potentially harmful if the underlying cause of the elevated respiratory rate is not related to oxygenation issues. D) Administering a sedative medication (option D) would be contraindicated as it could further depress the respiratory drive and worsen the client's condition if respiratory distress is present. Educational context: Understanding the significance of vital sign assessment is crucial for nurses to provide safe and effective care to their patients. Abnormal vital signs, such as an elevated respiratory rate, can indicate underlying health problems that require prompt assessment and intervention. Nurses should always prioritize assessing for signs of distress or changes in vital signs to provide timely and appropriate care to their patients.