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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. He has an electrical burn, which caused coagulation of some tissues:
This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.
B. He is doing well, although he might be in the hospital for some time:
While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.
C. He does not appear to have much damage and should be fine soon:
This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.
D. He has an electrical burn. He is stable, and we will update you with any changes:
This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.
Correct Answer is B
Explanation
A. Round and Taut:
A round and taut abdomen may be normal, depending on the individual's body habitus and muscle tone. It might indicate normal abdominal distension associated with gas or a meal.
B. White Striae (Stretch Marks)
White striae, commonly known as stretch marks, on the abdomen may warrant further investigation. While they are often benign and associated with conditions like weight gain or pregnancy, they can sometimes be indicative of underlying issues such as Cushing's syndrome or other factors. Further inquiry or investigation into the client's medical history may be needed to understand the cause of the white striae.
C. Symmetrical, Rounded Shape:
A symmetrical and rounded abdominal shape is generally considered a normal finding. It suggests that the abdominal muscles are intact and that there is no obvious asymmetry or abnormal protrusion.
D. Soft and Non-Tender:
A soft and non-tender abdomen is a normal finding. It suggests that the abdominal
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