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. Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.
Correct Answer is C
Explanation
A. Telling the child that it will not hurt may not be effective, as children may still have anxiety or fear related to the unknown.
B. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure.
C. Allowing the child to operate the equipment can give the child a sense of control and involvement, increasing cooperation.
D. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.
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