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: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

A. Remove excess clothing from the client. B. Restrict the client's fluid intake. C. Place a warming blanket over the client. D. increase the temperature in the client's room.

Correct Answer is A

Explanation

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

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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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