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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using technical language can confuse the client and hinder understanding. Educational sessions should use clear and simple language.
B. Starting with the least important information may lead to client confusion or lack of retention of critical details about the medication. Important information should be prioritized.
C. Turning on the television can be distracting for the client, making it difficult for them to focus on the medication education. A quiet environment is more conducive to learning.
D. Providing educational material written at a 6th grade reading level ensures that the information is accessible and understandable for the client, promoting better comprehension and adherence to medication regimens.
Correct Answer is A
Explanation
A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.
B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.
C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.
D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.
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