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) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.

Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.

Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.

Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.

A. Pulse and blood pressure findings B. Scheduled treatments and client illness C. A self-report pain rating scale D. Behavioral indicators and aﬀect

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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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

Correct Answer is B

Explanation

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Correct Answer is C

Explanation

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