A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?
After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse.
Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min.
Measure the client's apical pulse while another nurse measures their radial pulse.
Assess both of the client's radial pulses at the same time and compare the quality of pulsations.
The Correct Answer is C
Rationale:
A. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This technique assesses blood pressure, not pulse deficit. Pulse deficit requires comparing simultaneous heartbeats at different sites rather than using a cuff for measurement.
B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This evaluates orthostatic changes in heart rate, not pulse deficit. Pulse deficit specifically identifies a difference between apical and peripheral pulses during the same cardiac cycle.
C. Measure the client's apical pulse while another nurse measures their radial pulse: A pulse deficit is determined by counting the apical pulse and comparing it to the radial pulse simultaneously. A difference indicates that some heartbeats are not producing a palpable peripheral pulse, which is important in conditions like atrial fibrillation.
D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing radial pulses on both sides evaluates for peripheral pulse equality or arterial obstruction, not pulse deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Avoid consuming grapefruit juice while taking this medication.": Grapefruit juice inhibits the cytochrome P450 enzyme system in the liver, leading to increased serum levels of nifedipine. This can potentiate adverse effects such as hypotension, dizziness, and tachycardia.
B. "Your magnesium level will be monitored while taking this medication.": Nifedipine, a calcium channel blocker, does not significantly affect magnesium levels. Monitoring magnesium is more relevant for clients receiving magnesium sulfate.
C. "This medication can cause changes in thyroid function.": Nifedipine has no known effects on thyroid hormones or gland function. Drugs affecting thyroid function include amiodarone or lithium, not calcium channel blockers like nifedipine.
D. "This medication can cause an increase in blood glucose levels.": Nifedipine does not alter glucose metabolism. Medications such as corticosteroids and thiazide diuretics are more likely to cause hyperglycemia, whereas nifedipine’s primary effects involve smooth muscle relaxation and vasodilation.
Correct Answer is C
Explanation
Rationale:
A. Hypovolemia: Hypovolemia causes a decrease in PAWP due to reduced circulating blood volume and inadequate venous return to the heart. A low PAWP reflects decreased left ventricular preload, not an elevated value.
B. Hypotension: Hypotension alone does not directly increase PAWP. In fact, low blood pressure often accompanies decreased cardiac filling pressures. Elevated PAWP typically occurs with fluid overload or impaired ventricular function rather than simple hypotension.
C. Left ventricular failure: An elevated PAWP indicates increased left-sided heart pressures due to ineffective left ventricular pumping. Blood backs up into the pulmonary circulation, leading to pulmonary congestion and edema.
D. Cardiogenic shock: In cardiogenic shock, PAWP can be elevated due to impaired contractility, but it is accompanied by low cardiac output and hypotension. While related, the elevated PAWP in cardiogenic shock results from the underlying left ventricular failure, which is the primary cause of the pressure increase.
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