A nurse is caring for a client who has a dysrhythmia. Which of the following techniques is appropriate for the nurse to use to assess for a pulse deficit?
Obtain apical and radial rates simultaneously.
Palpate pulses in the lower extremities.
Check blood pressure in left and right arms.
Compare the pulse strength in upper extremities.
The Correct Answer is A
A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).
B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.
C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.
C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.
Correct Answer is C
Explanation
A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.
B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.
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