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A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?

A.

Measure the client's apical pulse while another nurse measures their radial pulse.

B.

After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse.

C.

Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min.

D.

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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Related Questions

Correct Answer is C

Explanation

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale:

  • "We should expect the swelling and tingling to worsen before it gets better." This statement needs reinforcement because worsening swelling and tingling can indicate early signs of compartment syndrome. These symptoms are not normal and should prompt immediate medical attention.
  • "It is important that our child avoids placing anything inside the cast." This statement reflects understanding because inserting objects inside the cast can break the skin and introduce bacteria, leading to infection. It may also damage the padding and compromise skin protection.
  • "We should prop the casted arm on pillows for the next 24 hours." Elevating the limb helps reduce swelling and pain by improving venous return. Keeping the casted arm elevated is a standard part of cast care teaching after an injury.
  • "We should notify the provider if the cast becomes loose over time." A loose cast may no longer immobilize the fracture effectively and can allow excessive movement. It may also rub the skin, increasing the risk of irritation or breakdown.
  • "We need to be very careful about how we handle the cast for the first 2 days while it dries." This shows understanding because a plaster cast takes 24 to 48 hours to fully dry. Improper handling can cause pressure indentations, leading to skin damage and poor cast integrity.

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