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 technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Ensure that the call bell is easily accessible to the client.
Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.
Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.
Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.
Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.
Correct Answer is D
Explanation
Choice A rationale:
Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.
Choice B rationale:
Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.
Choice C rationale:
Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.
Choice D rationale:
Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.
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