A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the pedal pulses with a Doppler device

Assess the pedal pulses for a full minute

Assess the apical pulse with a Doppler device

Assess the apical pulse for a full minute

Answer and Explanation

The Correct Answer is D

A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.

B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.

C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.

D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.

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Correct Answer is C

Explanation

A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.

B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.

C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.

D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.

A. In the area where the nurse obtained the medication. B. At the time of documentation. C. At the client's bedside before administration. D. At the nurses' station while reviewing the provider's prescription.

Correct Answer is C

Explanation

A. Performing the final medication check in the area where the medication was obtained does not ensure the correct patient is receiving the medication.

B. Documenting after administration does not allow for a final check of the medication against the patient’s identity and allergies.

C. Performing the final check at the client's bedside before administration allows the nurse to confirm the patient's identity, the medication's appropriateness, and the dosage immediately before giving it.

D. Reviewing the prescription at the nurses' station may not account for patient-specific factors that need to be confirmed at the bedside.

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A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

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