The nurse finds a client's pulse to be very weak, but palpable. Documentation should note that this pulse is:
hypovolemic.
bradycardic.
deficient.
thready.
The Correct Answer is D
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.
A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.
B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.
C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.
Correct Answer is B
Explanation
B. This response acknowledges the urgency of the situation and seeks clarification on the appropriate administration technique. It demonstrates readiness to follow through with the medical resident's directive while ensuring safe and effective administration.
A. This response reflects hesitation and a concern about administering a medication that the nurse did not prepare or is unfamiliar with. In a critical situation like a "code blue," timely administration of medications as directed by the medical team is crucial for patient outcomes.
C. Checking IV patency is important to ensure the medication can be administered properly. However, in a "code blue" situation where time is critical, this step might unnecessarily delay administration of the medication.
D. This response indicates willingness to follow the directive given by the medical resident. It also emphasizes the importance of documenting and obtaining proper orders after the immediate crisis has been addressed.
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