The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:
count the radial pulse for two minutes."
put my fingers on the "pinky" finger side of the wrist."
use my thumb to count the pulse."
count the pulse for 30 seconds and multiply the number by two
The Correct Answer is D
D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.
A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).
B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.
C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Bathing can indeed foster a nurse-client relationship. It provides an opportunity for interaction and communication between the nurse and the client, promoting trust and rapport.
B Bathing can contribute to the client's overall sense of well-being. It promotes comfort, relaxation, and a feeling of cleanliness, which are important aspects of holistic care.
C. Bathing allows the nurse to visually assess the client's skin integrity. During the process, the nurse can identify any changes in skin color, presence of lesions, wounds, or other abnormalities that may require further assessment or intervention.
D. Bathing, particularly when accompanied by gentle massage or movement of limbs, can stimulate circulation. This helps improve blood flow to tissues, aiding in wound healing and reducing the risk of complications such as pressure ulcers.
E. Depending on the type of bath products used (e.g., moisturizing soap or bath oils), bathing can help moisturize the skin. This is especially beneficial for clients with dry skin or conditions that predispose them to skin dryness.
Correct Answer is B
Explanation
B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube
A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.
C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.
D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.
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