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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B: Monitor the client's hearing. Choice A rationale:

Observing the skin for a rash is not relevant to assessing for signs of ototoxicity. Aminoglycosides can cause skin reactions, but this is not a specific sign of ototoxicity.

Choice B rationale:

Monitoring the client's hearing is essential when administering aminoglycosides because these medications can cause ototoxicity, which is damage to the inner ear and auditory nerve leading to hearing loss or tinnitus. Regular hearing assessments can help detect any changes in hearing and prompt appropriate interventions.

Choice C rationale:

Measuring the urinary output is not directly related to assessing for ototoxicity.

Aminoglycosides can cause kidney toxicity, but this is a separate concern from ototoxicity. Choice D rationale:

Checking for changes in vision is not specifically associated with aminoglycoside administration. Vision changes are not a common side effect of these medications, so it would not be a primary assessment in this situation.

A. Review the client's expectations of elimination after surgery. B. Verify that the client had nothing by mouth (NPO) for the past 24 hours. C. Ask the client if he finished the bowel sterilization prescription. D. Determine if this is the first indwelling catheter the client has had.

Correct Answer is A

Explanation

This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will aﬀect the client's elimination and body image.

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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?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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