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 B
Explanation
The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:
Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.
Choice B rationale:
Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.
Choice C rationale:
Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.
Choice D rationale:
Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.
Correct Answer is D
Explanation
Observe the UAP's technique and communication skills during the bath.
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
- Asking another UAP to help the orientee may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
- Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
- Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
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