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 B
Explanation
Rationale:
A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.
B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.
C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.
D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.
Correct Answer is A
Explanation
Rationale:
A. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.
B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.
C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.
D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.
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