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 D

Explanation

A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.

B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.

C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.

D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.

A. Use an alcohol-based agent to perform hand hygiene when caring for the client. B. Obtain a blood specimen to test for C. difficile. C. Place the client on contact precautions. D. Place a surgical mask on the client during transport.

Correct Answer is C

Explanation

A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.

B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.

C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.

D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.

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