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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.

B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.

C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.

D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.

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

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.

B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.

D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.

E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.

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