N125 Exam 1 Study Guide with
Complete Solutions
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
a.Is used to listen for high-pitched sounds.
b.Is used to listen for low-pitched sounds.
c.Should be lightly held against the person's skin to block out low-pitched sounds.
d.Should be lightly held against the person's skin to listen for extra heart sounds and
murmurs. - ANSWER-A
What is the major health problem resulting from a pulse deficit?
1. Bradycardia
2. Activity intolerance
3. Decreased cardiac output
4. Impaired tissue perfusion - ANSWER-3
Decreased cardiac output is the major problem indicated by a pulse deficit. Decreased
cardiac output may lead to other problems, such as activity intolerance.
Bradycardia is a pulse rate less than 60 beats/minute. This can occur without a pulse
deficit.
Impaired tissue perfusion may or may not occur with a pulse deficit. Decreased cardiac
output may lead to impaired tissue perfusion. A cardiac dysrhythmia may lead to
impaired tissue perfusion, but the impaired perfusion itself is not the most important
possible result of the dysrhythmia.
What should the nurse do when a pulse deficit is suspected?
1. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1
minute.
2. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30
seconds.
3. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical
pulse for 1 minute.
4. Ask another health care provider to count the radial pulse while the nurse counts the
apical pulse. - ANSWER-4.
, The nurse counts the apical pulse while another health care provider counts the radial
pulse.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment?
1. An accurate temperature reading is obtained with moisture on the forehead.
2. Put on a disposable sensor cover before taking the temporal artery temperature.
3. Place the sensor flush on the patient's forehead.
4. Obtain the temperature reading on the lower neck. - ANSWER-3
Placement of the sensor on a temporal artery thermometer is flush on the patient's
forehead. The thermometer remains flush on the skin as the NAP slides it across the
forehead.
The sensor confirms the highest temperature reading behind the earlobe.
Inadequate oxygenation to the body will cause the radial pulse to become:
1. Tachycardic
2. Bradycardic
3. Irregular
4. Bounding - ANSWER-1
The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is
more than 100 beats/minute.
What is the primary purpose of initially assessing an apical pulse?
1. Assessment of the patient's cardiac function
2. Establishment of a baseline as part of the patient's vital signs
3. Assessment of the patient's risk for cardiovascular disease
4. Determination of oxygen saturation - ANSWER-2
Which action would take priority if a patient's apical pulse has an irregular rhythm?
1. Reassess the pulse for 1 full minute.
2. Assess the patient's peripheral pulses.
3. Wait 5 minutes, and then reassess the apical pulse.
4. Review documentation regarding an irregular rhythm. - ANSWER-1
A second measurement confirms the initial findings of an irregular heart rate. Irregular
rate is more accurately assessed when measured over a longer interval.
Complete Solutions
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
a.Is used to listen for high-pitched sounds.
b.Is used to listen for low-pitched sounds.
c.Should be lightly held against the person's skin to block out low-pitched sounds.
d.Should be lightly held against the person's skin to listen for extra heart sounds and
murmurs. - ANSWER-A
What is the major health problem resulting from a pulse deficit?
1. Bradycardia
2. Activity intolerance
3. Decreased cardiac output
4. Impaired tissue perfusion - ANSWER-3
Decreased cardiac output is the major problem indicated by a pulse deficit. Decreased
cardiac output may lead to other problems, such as activity intolerance.
Bradycardia is a pulse rate less than 60 beats/minute. This can occur without a pulse
deficit.
Impaired tissue perfusion may or may not occur with a pulse deficit. Decreased cardiac
output may lead to impaired tissue perfusion. A cardiac dysrhythmia may lead to
impaired tissue perfusion, but the impaired perfusion itself is not the most important
possible result of the dysrhythmia.
What should the nurse do when a pulse deficit is suspected?
1. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1
minute.
2. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30
seconds.
3. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical
pulse for 1 minute.
4. Ask another health care provider to count the radial pulse while the nurse counts the
apical pulse. - ANSWER-4.
, The nurse counts the apical pulse while another health care provider counts the radial
pulse.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is
applicable only to temporal artery temperature assessment?
1. An accurate temperature reading is obtained with moisture on the forehead.
2. Put on a disposable sensor cover before taking the temporal artery temperature.
3. Place the sensor flush on the patient's forehead.
4. Obtain the temperature reading on the lower neck. - ANSWER-3
Placement of the sensor on a temporal artery thermometer is flush on the patient's
forehead. The thermometer remains flush on the skin as the NAP slides it across the
forehead.
The sensor confirms the highest temperature reading behind the earlobe.
Inadequate oxygenation to the body will cause the radial pulse to become:
1. Tachycardic
2. Bradycardic
3. Irregular
4. Bounding - ANSWER-1
The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is
more than 100 beats/minute.
What is the primary purpose of initially assessing an apical pulse?
1. Assessment of the patient's cardiac function
2. Establishment of a baseline as part of the patient's vital signs
3. Assessment of the patient's risk for cardiovascular disease
4. Determination of oxygen saturation - ANSWER-2
Which action would take priority if a patient's apical pulse has an irregular rhythm?
1. Reassess the pulse for 1 full minute.
2. Assess the patient's peripheral pulses.
3. Wait 5 minutes, and then reassess the apical pulse.
4. Review documentation regarding an irregular rhythm. - ANSWER-1
A second measurement confirms the initial findings of an irregular heart rate. Irregular
rate is more accurately assessed when measured over a longer interval.
