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 C
Explanation
Choice A rationale:
Modified equivalents. This is not the correct answer. The abbreviation "mEq" stands for milliequivalents, not modified equivalents.
Choice B rationale:
Megaequivalents. This is not the correct answer. "Mega" is a prefix indicating a factor of one million. In the context of electrolytes and medications, milliequivalents (mEq) are the appropriate unit of measurement, not megaequivalents.
Choice C rationale:
Milliequivalents. This is the correct answer. Milliequivalents (mEq) are a measure of the chemical combining power of a substance. In medical contexts, mEq is often used to express the amount of electrolytes (such as potassium, sodium, calcium) in a solution or dosage form. It represents 1/1000th of an equivalent, which is the amount of a substance that can react with or replace one mole of hydrogen ions (H+) It is important for healthcare professionals to understand these units when dealing with medications and intravenous fluids, as incorrect administration can lead to serious health complications.
Choice D rationale:
Miniequivalents. This is not the correct answer. "Mini" is not a standard prefix used in the International System of Units (SI) The correct prefix for a thousandth of an equivalent is "milli," making milliequivalents the appropriate unit of measurement for substances like electrolytes.
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.
Choice B rationale:
Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.
Choice C rationale:
Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.
Choice D rationale:
Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.
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