A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular

Bounding

Not palpable

Slow

Answer and Explanation

The Correct Answer is A

A In atrial fibrillation (AF), the electrical activity in the atria is chaotic, leading to an irregularly irregular ventricular response. As a result, the pulse felt at the radial artery will be irregular, with no discernible pattern. The irregularity is a hallmark feature of AF and is often described as "irregularly irregular."

B Bounding pulses are characterized by a strong and forceful pulsation felt at the arterial pulse sites. In atrial fibrillation, the irregular and rapid ventricular response can lead to an increased stroke volume and forceful contraction of the left ventricle during diastole, resulting in bounding pulses. However, bounding pulses are not typically associated with atrial fibrillation; they are more commonly seen in conditions such as aortic regurgitation or hyperdynamic circulation.

C In some cases of atrial fibrillation, especially if the ventricular rate is very rapid or irregularly irregular, the pulse may not be palpable due to the inconsistent ventricular contractions.

However, in most cases of atrial fibrillation, a pulse is palpable, albeit irregular.

D Atrial fibrillation can result in a rapid ventricular response, leading to a fast heart rate. However, the pulse rate can vary widely among individuals with atrial fibrillation. While some may have a rapid heart rate (tachycardia), others may have a slower heart rate (bradycardia), depending on factors such as concomitant medications, autonomic tone, and the presence of underlying heart disease.

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Correct Answer is B

Explanation

B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.

A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.

C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.

D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.

A. Initiation of continuous positive pressure ventilation (CPAP) B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Administration of 100% 02 by non-rebreather mask

Correct Answer is B

Explanation

B. Endotracheal intubation and positive pressure ventilation are indicated in patients with severe respiratory failure who are unable to maintain adequate oxygenation and ventilation on their own. This intervention provides mechanical support to the patient's breathing by delivering positive pressure to the lungs via an endotracheal tube. Given the patient's respiratory rate of 6 breaths/min, low oxygen saturation (SpO2 of 78%), and increasing lethargy, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and ventilation.

A. CPAP is a form of non-invasive positive pressure ventilation that helps keep the airways open and improves oxygenation. However, in a patient with severe respiratory failure and impending respiratory arrest, CPAP alone may not be sufficient to adequately support ventilation and oxygenation. CPAP is typically used in patients with milder forms of respiratory failure or as a step-down therapy from invasive mechanical ventilation.

C. Insertion of a mini-tracheostomy is not typically indicated in a patient with severe respiratory failure and impending respiratory arrest. While tracheostomy may be considered in certain cases for long-term ventilation or airway management, it is not the first-line intervention in an acute situation like this.

Additionally, frequent suctioning may not address the underlying cause of respiratory failure or improve oxygenation.

D. Administering 100% oxygen via a non-rebreather mask can help improve oxygenation temporarily. However, in a patient with severe respiratory failure and impending respiratory arrest, non-invasive oxygen therapy alone may not be sufficient to maintain adequate oxygenation and ventilation.

Endotracheal intubation and positive pressure ventilation are more definitive interventions to ensure adequate support for the patient's breathing.

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A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Nursing Test Bank

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Correct Answer is B

Explanation

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