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 B
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
Correct Answer is A
Explanation
A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.
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