Author Question: An expected finding from an apical pulse measurement includes: A. Mild dysrhythmia B. A rate of ... (Read 58 times)

ENagel · **on:** Jul 24, 2018

An expected finding from an apical pulse measurement includes:

A. Mild dysrhythmia
B. A rate of more than 100 beats per minute
C. A nonpalpable PMI
D. High-pitched S1 and S2 sounds

Question 2

If the skin around the dressing appears red and irritated, the nurse should avoid the use of:

A. Tape
B. Gauze
C. Montgomery ties
D. Strips of hydrocolloid dressing

javimendoza7 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
D. Normal sounds S1 and S2 are high pitched and best heard with the diaphragm.
A. If heart rate is irregular, or client is receiving cardiovascular medication, count for 1 minute (60 seconds). Regular occurrence of dysrhythmia within 1 minute may indicate inefficient contraction of heart and alteration in cardiac output.
B. If heart rate is irregular, or client is receiving cardiovascular medication, count for 1 minute (60 seconds).
C. If unable to palpate the PMI, reposition client on left side. In the presence of serious heart disease, the PMI may be located to the left of the MCL or at the sixth ICS.

Answer to Question 2

A
A, C, and D. If areas of redness appear from tape, then paper tape or alternatives such as elastic bandage, Kerlix, or a binder may be used to secure dressing. Sometimes strips of a hydrocolloid dressing are placed on the skin under the Montgomery ties to further protect the skin.
B. Gauze is not contraindicated in cases of redness.