Author Question: Which outcome best reflects achievement of the goal, The client will demonstrate correct steps in ... (Read 109 times)

Deast7027 · **on:** Jul 22, 2018

Which outcome best reflects achievement of the goal, The client will demonstrate correct steps in taking his own pulse rate?

A) firm placement of thumb on the inner wrist of the opposite arm
B) palpation of the radial pulse on the thumb side of the inner aspect of the wrist.
C) light palpation of the femoral pulse below the inguinal area
D) firm palpation of bilateral carotid artery for one minute

Question 2

The nurse observes the client's frequent use of the incentive spirometer. The client states I do not want to have pneumonia while in the hospital. Which vital sign reading demonstrates effectiveness of this intervention?

A) Respiratory rate of 12 breaths per minute
B) Blood pressure of 126/84 mmHg
C) Temperature of 98.2 degrees Fahrenheit
D) Pulse rate of 100 beats per minute

ambernicolefink · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

Ans: B
Feedback:
The radial artery is the site most commonly assessed in the clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist.

Answer to Question 2

Ans: C
Feedback:
Emotional or physical stress can elevate body temperature. When stress stimulates the sympathetic nervous system, circulating levels of epinephrine and norepinephrine increase. As a result, the metabolic rate increases, which, in turn, increases heat production. Stressed or anxious clients may have an elevated temperature with no underlying pathology.