An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?
Left 5th intercostal space midclavicular line
Right carotid area
Over the brachial artery
Over the sternum
The Correct Answer is C
A. Left 5th intercostal space midclavicular line: Palpating the left 5th intercostal space midclavicular line is not appropriate for assessing pulse in an unresponsive infant. This location is typically used for cardiac auscultation and not for pulse assessment.
B. Right carotid area: Palpating the carotid artery is not recommended in infants due to the risk of causing injury to the delicate structures of the neck, including the
airway and blood vessels.
C. Over the brachial artery: The brachial artery is the preferred site for assessing pulse in infants. It is located in the inner aspect of the upper arm and can be easily palpated. In an unresponsive infant, the brachial pulse should be assessed before
initiating CPR.
D. Over the sternum: Palpating over the sternum is not an appropriate site for pulse assessment in infants. The sternum is a bone and does not contain any major arteries suitable for pulse palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect
catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.
D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.
Correct Answer is B
Explanation
A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.
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