The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .

Choice D rationale:

When preparing to open a sterile pack, the nurse must touch only the inner surface of the inner wrapper to maintain sterility. This is a fundamental principle of aseptic technique. Sterile items should be handled with care to prevent contamination. By touching only the inner surface of the inner wrapper, the nurse ensures that the contents of the pack remain sterile and safe for use in medical procedures. Any contact with the outer surface or other non-sterile items can compromise the sterility of the contents.

Choice A rationale:

Placing the sterile pack on a clean surface is a good practice but does not ensure the maintenance of sterility. Sterile items should be placed on a sterile surface or field to prevent contamination. Placing the pack on a clean surface may still expose it to potential contaminants, compromising its sterility.

Choice B rationale:

Turning the pack so that the first flap faces the nurse's body is incorrect. The first flap should be opened away from the nurse to avoid the risk of contamination. By opening the flap away from the nurse, any potential contaminants in the air are less likely to come into contact with the sterile contents.

Choice C rationale:

Opening the right-side flap first is not a standard practice for opening a sterile pack. The choice of which side to open first may vary based on individual preference or the design of the packaging. The key factor is to maintain the sterility of the contents by handling the pack appropriately, as mentioned in choice D.