A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first?

Request assistance from a second nurse.

Count the client's apical pulse.

Check the client's pulse rate for 1 min.

Calculate the difference between the client's peripheral pulse and the client's apical pulse.

Answer and Explanation

The Correct Answer is A

A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.

C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.

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Correct Answer is A

Explanation

A. The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B. The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C. The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D. The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

A. Rales B. Stridor C. wheezes D. Rhonchi

Correct Answer is B

Explanation

A: Rales are described as fine crackling sounds, not high-pitched crowing.

B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.

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A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first?

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