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 B
Explanation
Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D rationale:
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Correct Answer is ["A","C","E"]
Explanation
The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:
A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.
C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.
E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .
The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:
B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .
D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today