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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:
A. Call in additional medical-surgical unit nursing care staff: Calling in staff may be part of the overall disaster plan but is typically coordinated by administration or the incident command team, not by individual unit nurses.

B. Act as a liaison between the facility and the media: Communication with the media is the responsibility of the facility’s public information officer or designated spokesperson, not bedside nurses.

C. Determine the medical needs of incoming clients through the emergency department: Triage and assessment of incoming clients occur in the emergency department by the triage nurse or emergency staff, not on the medical-surgical unit.

D. Recommend to the provider specific acute care clients for discharge: In a mass casualty event, medical-surgical nurses help identify stable clients who can be safely discharged or transferred to make room for incoming critical clients. This is an essential role in surge capacity management.

A. A client who has an open compound fracture of the humerus B. A client who has multiple facial lacerations C. A client who has a puncture wound in the right lower lung D. A client who has full-thickness burns over the lower extremities

Correct Answer is B

Explanation

Rationale:
A. A client who has an open compound fracture of the humerus: A compound fracture involves broken bone protruding through the skin and carries a risk of infection and significant blood loss. This client requires urgent care and should be tagged yellow (delayed) or red (immediate) depending on other injuries.

B. A client who has multiple facial lacerations: Facial lacerations that are not life-threatening can be treated after higher-acuity clients are stabilized. These clients are mobile, alert, and their injuries are minor, which qualifies them for a green tag (minimal, “walking wounded”).

C. A client who has a puncture wound in the right lower lung: A puncture wound to the lung can compromise respiratory function and oxygenation. This is a life-threatening injury, requiring immediate intervention and a red tag.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns compromise skin integrity and can lead to fluid loss, infection, and shock. This client needs urgent treatment and should be tagged red (immediate) or yellow (delayed) depending on the extent of burns and airway status.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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