A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
Use the diaphragm of the stethoscope to listen to the apical pulsations
Count the apical pulsations for a full minute
Press the stethoscope firmly against the client's skin
Check the apical pulse with a Doppler device
The Correct Answer is B
Choice A reason: The diaphragm of the stethoscope is used for high-pitched sounds such as breath sounds, bowel, and normal heart sounds. For the apical pulse, which involves listening to the heart's sounds, the bell of the stethoscope is often recommended, especially for lower-pitched sounds like murmurs.
Choice B reason: Counting the apical pulsations for a full minute is the correct action when assessing the apical pulse, particularly for clients on cardiovascular medications. This ensures accuracy in detecting any irregularities or changes in the heart rate that could be affected by the medications.
Choice C reason: The stethoscope should be placed gently against the client's skin. Pressing too firmly can distort the heart sounds, making it difficult to accurately assess the apical pulse.
Choice D reason: A Doppler device is not typically used for routine assessment of the apical pulse. It is more commonly used when pulses are difficult to palpate or auscultate, such as in cases of peripheral arterial disease.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Thoroughly cleansing the affected area helps remove potential pathogens. The Centers for Disease Control and Prevention (CDC) advises washing needlestick injuries with soap and water.
Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.
Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.
Choice D reason: If indicated, postexposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours of exposure, to maximize its effectiveness. Delaying PEP until the following day is not advisable.
Correct Answer is A
Explanation
Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.
Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.
Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.
Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.
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