After noting that a client has a pulse deficit, what action should the nurse take next?
Instruct the client to report for weekly re-evaluations by the nurse.
Teach the client how to check pulses at home.
Report this finding to the physician.
Document this finding.
The Correct Answer is C
A. Instruct the client to report for weekly re-evaluations by the nurse. A pulse deficit indicates a difference between the apical and radial pulse rates, which may suggest cardiac dysfunction such as atrial fibrillation. This requires immediate evaluation, not just weekly monitoring.
B. Teach the client how to check pulses at home. While patient education is important, a pulse deficit is a clinical concern that should be addressed by a healthcare provider before self-monitoring is advised.
C. Report this finding to the physician. A pulse deficit may indicate arrhythmias or decreased cardiac output, requiring further evaluation and possible medical intervention. The physician should be informed promptly.
D. Document this finding. While documentation is necessary, the priority action is to report the pulse deficit to the physician so appropriate diagnostic tests and interventions can be initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Family members report that pain has subsided. Pain is a subjective experience, and the patient's own report is the most reliable indicator of pain relief, not the observations of family members.
B. Vital signs have returned to baseline. While pain can affect vital signs, such as increasing heart rate or blood pressure, their return to normal does not necessarily indicate adequate pain relief. Some patients may still experience significant pain despite stable vital signs.
C. Body language is incongruent with reports of pain relief. Nonverbal cues can be helpful in assessing pain, but they should not override the patient’s self-reported pain level, which is the most accurate measure.
D. You compare assessed pain with baseline pain. The best way to evaluate the effectiveness of PCA analgesia is to assess the patient’s pain level before and after medication administration, comparing it to baseline pain. This provides an objective measure of pain relief.
Correct Answer is C
Explanation
A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.