A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?
Measure the client's apical pulse while another nurse measures their radial pulse.
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.
Assess both of the client's radial pulses at the same time and compare the quality of pulsations.
The Correct Answer is A
Rationale:
A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.
B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.
C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.
D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Every so often, I think about whether or not to have this surgery.": This statement suggests the client is still ambivalent or uncertain, which means informed consent has not yet been fully achieved. Clients must be sure and fully informed before agreeing to proceed.
B. "I will talk with the doctor about my surgery when I get into the operating room.": Informed consent must be obtained well before the procedure begins. Waiting until the operating room is inappropriate, as the client may be under stress or sedation.
C. "Can you tell me more about the surgery I am having?": This indicates the client lacks essential information about the procedure. Informed consent requires that the client already understand the nature, risks, benefits, and alternatives before signing.
D. "Signing this form indicates that I give my permission for the surgery, right?": This reflects an understanding that the consent form gives legal authorization for the procedure. It shows the client knows their signature confirms informed agreement to the surgery.
Correct Answer is B
Explanation
Rationale:
A. Obtaining the initial assessment of assigned clients: Initial assessments require nursing judgment and are part of the nursing process, which cannot be delegated to assistive personnel. Only licensed nurses may perform comprehensive initial assessments.
B. Changing a nonsterile dressing: This is a routine and predictable task that does not require clinical judgment and can be safely delegated to assistive personnel, depending on facility policy and the client’s condition.
C. Interpreting a client's diagnostic laboratory results: Interpretation of lab values requires analysis and clinical decision-making, which are nursing responsibilities. Assistive personnel are not licensed to interpret or evaluate clinical data.
D. Educating a client and family members on home care: Client education involves assessing understanding, using clinical knowledge, and adapting teaching methods, functions reserved for licensed nurses, not assistive personnel.
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