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 ["A","B","F"]

Explanation

Rationale:
A. Elevate the affected forearm with pillows: Elevation helps reduce swelling and promotes venous return, which is critical in the immediate management of a fracture to prevent complications such as increased edema or impaired circulation.

B. Administer Ibuprofen 200 mg PO: The child reports pain at a level of 5, meeting the prescription threshold. Administering analgesia promptly helps manage discomfort and supports cooperation with further interventions, such as casting.

C. Place a nonadherent dressing on the right knee abrasion: While wound care is important, the abrasion is minor and not the most urgent concern. Prioritization focuses on the fractured limb and pain management.

D. Review cast care instructions with the child's parents: Education is important but is not the immediate priority before the cast is applied. It can be provided after the child is stabilized and pain is managed.

E. Explain the cast application procedure to the child: While preparing the child psychologically is important, immediate interventions to reduce pain and swelling take precedence over anticipatory teaching.

F. Apply ice packs to the fingers and along the right forearm: Ice helps reduce swelling and pain in the acute phase of the fracture. Applying ice in combination with elevation supports circulation and comfort while awaiting casting.

A. Assess the client's lung sounds prior to the infusion. B. Prime the infusion tubing with 0.45% sodium chloride. C. Don sterile gloves to prepare the blood administration setup. D. Verify with another nurse that the unit of blood is compatible with the client's blood type. E. Infuse the blood over 4 hr.

Correct Answer is ["A","D"]

Explanation

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. A single blood administration set should not be used for more than 4 hours total due to the risk of bacterial growth. More importantly, running 2 units over a single 4 hour window would mean infusing the blood far too quickly for an older adult, drastically increasing their risk of volume overload. Each unit should be scheduled separately with a careful assessment in between.

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