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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Eye exams are generally recommended more frequently, especially for older adults, to monitor for age-related changes and conditions.
B. Women should have a clinical breast examination every year, in addition to mammograms as recommended by their healthcare provider.
C. Both men and women should have a colonoscopy periodically, depending on individual risk factors and age.
D. Regular hearing screenings are important for older adults, especially as age-related hearing loss may occur.
E. Testicular self-exams are recommended for men to detect any abnormalities early on.

A. Keep the client's bed linens dry. B. Apply an alcohol-water solution to the client's skin. C. Encourage the client to drink 1,500 mL of fluid per day. D. Apply ice packs to the groin.

Correct Answer is A

Explanation

A. Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.

C. Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

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