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 A

Explanation

A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.

B. Documenting that the medication was administered should occur after the medication has been given, not before.

C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.

D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.

A. Inject the medication 12.7 cm (5 in) below the client's acromion process B. Use a 21-gauge needle for the injection C. Inject the medication at a 90-degree angle D. Inject a volume of less than 2 mL

Correct Answer is D

Explanation

A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.

B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.

C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.

D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.

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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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