A nurse notes a client's pulse is a 2+ and understands this means what about the pulse?
The pulse is an expected finding.
The pulse is full volume and bounding.
The pulse is increased and strong.
The pulse is absent.
The Correct Answer is B
Choice A rationale:
A pulse rating of 2+ is not considered an expected finding. It indicates a weaker pulse, which requires further assessment.
Choice B rationale:
A pulse rated as 2+ means the pulse is full volume and bounding. In clinical practice, a 2+ pulse is considered normal and signifies a pulse that is easily palpable and has a normal strength. This is an essential finding for the nurse to understand because it reflects the circulatory status of the client. A 2+ pulse suggests adequate perfusion and a healthy heart pumping blood effectively.
Choice C rationale:
A pulse rating of increased and strong corresponds to a higher numeric value on the scale, indicating a stronger pulse. A 2+ pulse is not categorized as increased but is rather a moderate strength pulse.
Choice D rationale:
A pulse rating of 2+ does not suggest an absent pulse. An absent pulse would mean that no pulse can be felt, which is a critical situation requiring immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.
Choice B rationale:
This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.
Choice C rationale:
This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.
Choice D rationale:
This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.
Correct Answer is D
Explanation
The correct answer is D. Determine the client's ability to help with the transfer.
Choice A rationale:
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
Choice B rationale:
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
Choice C rationale:
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
Choice D rationale:
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
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