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. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.
B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.
C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.
D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.
Correct Answer is D
Explanation
Rationale:
A. "Perform aerobic activities three times per week.": While exercise can be beneficial, excessive aerobic activity may worsen fatigue in clients with MS. Low-impact and well-paced exercise is more appropriate.
B. "Soak in a hot bath.": Heat can exacerbate symptoms in clients with MS by increasing nerve conduction issues, potentially leading to worsening fatigue or vision changes.
C. "Have your partner complete activities of daily living for you.": Encouraging dependence can contribute to decreased function and self-esteem. Clients should be supported to remain as independent as possible within their limits.
D. "Schedule rest periods during the day.": Fatigue is a common symptom of MS. Rest periods help conserve energy and prevent exacerbation of symptoms, promoting better overall functioning.
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