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

Asses the apical pulse with a doppler device

Assess the apical pulse for a full minute

Assess the pedal pulses for a full minute

Answer and Explanation

The Correct Answer is C

A. Assess the pedal pulses with a Doppler device:

Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.

B. Assess the apical pulse with a Doppler device:

While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.

C. Assess the apical pulse for a full minute:

This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.

D. Assess the pedal pulses for a full minute:

While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.

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Correct Answer is A

Explanation

A. The client:

The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.

B. Progress note:

Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.

C. Medical history:

The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.

D. Family information:

Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.

A. Edema B. Heart Rate C. Chills D. Pallor

Correct Answer is C

Explanation

A. Edema:

Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.

B. Heart Rate:

Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.

C. Chills

Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.

D. Pallor:

Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.

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