April 01, 2024 – NCLEX Practice Question

NCLEX Practice Question

April 01 , 2024


An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?
Nurse auscultates heart sounds at Erb’s point
Nurse palpates bilateral carotid arteries simultaneously
Nurse positions client at a 30-degree angle to assess for jugular venous distension
Nurse positions client’s hand near the heart level and squeezes the nail
  • Option 2
  • The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode.
  • Option 1
  • Erb’s point is located at the third left intercostal space near the sternum and is an appropriate location to auscultate heart sounds.
  • Option 3
  • Jugular venous distension should be assessed with the head of the bed at a 30- to 45-degree elevation.
  • Option 4
  • Capillary refill is assessed by positioning the client’s hand near the level of the heart and squeezing the nail bed to produce blanching. The nurse observes for return of color, which should occur in less than 2 seconds.
  • Educational objective:
  • The nurse should not palpate the carotid arteries simultaneously due to possible vagal stimulation resulting in bradycardia or syncope. Each carotid artery should be palpated separately.

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