A nurse is assessing the pulse of a client and has difficulty feeling the pulse. What would she do next?
Record the pulse as "o" (zero) for that site.
Use a doppler device to locate and assess the pulse.
Come back in 15 minutes and reassess.
Report the finding to the physician.
The Correct Answer is B
A. Record the pulse as "0" (zero) for that site. A pulse should never be documented as absent without first using a Doppler device to confirm whether blood flow is present.
B. Use a Doppler device to locate and assess the pulse. If a pulse is difficult to palpate, a Doppler ultrasound should be used to detect blood flow before making any conclusions about circulation status.
C. Come back in 15 minutes and reassess. If the pulse is weak or difficult to locate, immediate assessment with a Doppler is needed instead of delaying evaluation.
D. Report the finding to the physician. While a physician should be notified if a pulse remains undetectable even with a Doppler, the nurse must first verify the absence of a pulse before escalating the concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Axillary. The axillary method is less accurate because it measures surface temperature, which can be influenced by environmental factors and is typically lower than core temperature.
B. Rectal. The rectal route provides the most accurate core temperature measurement because it closely reflects internal body temperature and is less affected by external conditions. It is commonly used in critically ill patients and infants when precise measurements are needed.
C. Forehead. Forehead (temporal artery) thermometers provide a non-invasive method of measuring temperature but can be less accurate due to external factors like sweating or ambient temperature changes.
D. Oral. Oral temperature is commonly used and provides a good estimate of core temperature, but factors like recent eating, drinking, or mouth breathing can affect accuracy. Rectal temperature remains the most precise method.
Correct Answer is C
Explanation
A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.
B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.
C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Aging leads to arteriosclerosis, where blood vessels become stiffer, reducing their ability to expand and contract, which contributes to increased systolic blood pressure. This is a well-documented normal physiologic change in older adults.
D. Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.
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