A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Carotid

Popliteal

Radial

Apical

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.

Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.

Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.

Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect. Flushing of the skin is not a sign of hypovolemic shock, but rather of vasodilation or fever. Hypovolemic shock causes vasoconstriction and pale, cool, clammy skin.

Choice B Reason: This is correct. Oliguria is a decreased urine output that indicates reduced renal perfusion due to hypovolemia. The normal urine output for an adult is 0.5 to 1 mL/kg/hr.

Choice C Reason: This is incorrect. Hypertension is not a sign of hypovolemic shock, but rather of increased vascular resistance or ﬂuid overload. Hypovolemic shock causes hypotension due to decreased blood volume and cardiac output.

Choice D Reason: This is incorrect. Bradypnea is a slow respiratory rate that indicates respiratory depression or fatigue. Hypovolemic shock causes tachypnea due to hypoxia and increased metabolic demand.

A. Slow the rate to 50 mL/hr. B. Slow the rate to 20 mL/hr. C. Continue the rate at 125 mL/hr. D. Increase the rate to 250 mL/hr.

Correct Answer is C

Explanation

The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.

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A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

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