The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?
Thready pulse volume.
Missing pulse.
Light pressure applied to pulse.
Pulse skips beats.
The Correct Answer is A
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
B. A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
C. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
D. Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.
Choice A rationale:
Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.
Choice B rationale:
While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.
Choice C rationale:
Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.
Choice D rationale:
Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.
Correct Answer is D
Explanation
The correct answer is
Choice D rationale:
The practical nurse (PN) should review the client's risk factors for exercise intolerance that impact his quality of life. By doing so, the PN can assess the client's overall health and identify any potential issues that might contribute to his fatigue. This response shows the PN's concern for the client's well-being and is focused on exploring the root cause of his tiredness.
Choice A rationale:
Determining if the client can move to a residential home without lawn maintenance is not appropriate in response to his complaint about feeling tired. This option does not address the underlying issue and assumes the client is unable to care for his own lawn, which may not be the case.
Choice B rationale:
Recommending that the client retires from doing outdoor chores is also not appropriate. It assumes the client's fatigue is solely due to his age and disregards the possibility of other contributing factors that might be addressed.
Choice C rationale:
Advising the client that fatigue is a common characteristic of aging is not a comprehensive response. While fatigue can be related to aging, it is crucial to explore the specific reasons for the client's tiredness before assuming it is solely age-related.
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