The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?

Document the finding in the patient’s medical record.

Assess the brachial pulse for a pulse deficit.

Notify the health care provider immediately.

Count the patient’s apical pulse for one full minute.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats..

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Correct Answer is D

Explanation

Choice A reason: This is incorrect. Emission is the process by which an object emits heat or light. For example, the sun emits heat and light to the earth.

Choice B reason: This is incorrect. Radiation is the process by which heat or light travels through space or air without direct contact. For example, the heat from a fireplace radiates to the room.

Choice C reason: This is incorrect. Convection is the process by which heat is transferred by the movement of a fluid, such as air or water. For example, the warm air from a heater rises and circulates in the room.

Choice D reason: This is correct. Conduction is the process by which heat is transferred by direct contact between two objects. For example, the heat from the warmed blanket is conducted to the patient’s skin.

A. Assessment B. Implementation C. Diagnosis D. Evaluation

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because assessment is the step of the nursing process that involves collecting and organizing data about the patient's health status and needs. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is performing an assessment by gathering relevant information from the patient and other sources.

Choice B reason: This is an incorrect choice because implementation is the step of the nursing process that involves carrying out the planned nursing interventions to achieve the patient's goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an implementation by executing any actions or treatments for the patient.

Choice C reason: This is an incorrect choice because diagnosis is the step of the nursing process that involves analyzing and interpreting the data to identify the patient's actual or potential health problems. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing a diagnosis by making any judgments or conclusions about the patient's condition.

Choice D reason: This is an incorrect choice because evaluation is the step of the nursing process that involves measuring and comparing the patient's progress and outcomes with the expected goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an evaluation by assessing any changes or improvements in the patient's status.

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The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?

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