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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. Impaired physical mobility relative to muscle rigidity. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Self-care deficit relative to motor disturbance.

Correct Answer is A

Explanation

Choice A rationale:

Impaired physical mobility relative to muscle rigidity has the highest priority in the nursing care plan for a client diagnosed with Parkinson's disease. Parkinson's disease is characterized by motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Impaired physical mobility can significantly impact a patient's ability to perform activities of daily living and maintain independence. Addressing this issue is crucial to enhance the patient's quality of life and prevent complications such as falls.

Choice B rationale:

While the risk for aspiration relative to muscle weakness is a valid concern in Parkinson's disease, impaired physical mobility takes precedence as it directly affects the patient's ability to move, ambulate, and perform daily activities. Addressing mobility issues is fundamental to maintaining overall functioning and independence.

Choice C rationale:

The risk for constipation relative to immobility is important to address, but it is not the highest priority. Impaired physical mobility can lead to multiple complications, including constipation. However, improving mobility should be the primary focus to prevent a wide range of issues associated with Parkinson's disease.

Choice D rationale:

Self-care deficit relative to motor disturbance is a concern in Parkinson's disease, but it is not the highest priority. Impaired physical mobility directly impacts a patient's ability to engage in self-care activities. By addressing mobility issues first, the nurse can facilitate the patient's ability to perform self-care tasks more independently in the long run.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Correct Answer is A

Explanation

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