A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
Carotid
Brachial
Popliteal
Femoral
The Correct Answer is A
A. Carotid
The nurse should avoid assessing the carotid pulses bilaterally at the same time. The carotid arteries are major blood vessels supplying the head and neck with oxygenated blood. Simultaneously assessing both carotid pulses could potentially compromise blood flow to the brain, leading to a decrease in cerebral perfusion. This is particularly important in individuals with a history of cerebrovascular disease or other conditions affecting blood flow to the brain.
B. Brachial:
Assessing the brachial pulses bilaterally at the same time is generally acceptable. The brachial pulses are located in the upper arms.
C. Popliteal:
Assessing the popliteal pulses bilaterally at the same time is generally acceptable. The popliteal pulses are located behind the knee.
D. Femoral:
Assessing the femoral pulses bilaterally at the same time is generally acceptable. The femoral pulses are located in the groin area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor:
Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.
B. Jaundice:
Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.
C. Cyanosis:
Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.
D. Erythema:
Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.
Correct Answer is A
Explanation
A. Documentation is a communication tool for the interprofessional health care team
The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.
B. Documentation allows providers to monitor the nurse’s activities:
While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.
C. Documentation provides information to the client about financial charges:
The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.
D. Documentation provides information for a client audit:
While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.
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