Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making.

Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

Correct Answer: A

Rationale:
To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes.
Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate.
Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort.
Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

Correct Answer: A

Rationale:
To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse.
Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

Correct Answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important.
Choice A is incorrect as providing a vague reassurance does not address the patient's query.
Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect.
Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

Correct Answer: B

Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness.
Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.