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 B

Explanation

A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.

A. Check the blood pressure with the client in a supine position. B. Place the client in a sitting position. C. Determine the client's blood pressure 1 min after each position change. D. Assist the client into a standing position.

Correct Answer is A

Explanation

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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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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