The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?
Instruct the UAP to report any abnormal findings.
Remind the UAP to check the client's pulse volume.
Demonstrate the correct pulse site to the UAP.
Confirm the accuracy of the pulse rate obtained by the UAP.
The Correct Answer is C
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Electrolyte imbalances, particularly involving electrolytes like potassium, can lead to cardiac arrhythmias. Elevated blood pressure can strain the cardiovascular system, and mental status changes could indicate potential neurologic and cardiovascular involvement. Auscultating for an irregular heart rate helps identify any immediate cardiac issues that require intervention.
B) Incorrect- While monitoring sodium intake is important for clients with chronic kidney disease, it is not the most urgent action in this scenario. The presence of electrolyte imbalance, elevated blood pressure, and changes in mental status indicate a more acute concern that requires immediate assessment.
C) Incorrect- Documenting abdominal girth is relevant for assessing fluid status, but in this situation, the presence of electrolyte imbalance, elevated blood pressure, and mental status changes indicates a more critical issue that requires prompt intervention.
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
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