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:
- 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.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- 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 C
Explanation
The correct answer is Choice C:
Suggest that an increase in fruits and vegetables is more beneficial.
Choice C rationale:
While dairy products do provide essential nutrients like calcium and vitamin D, there is no strong evidence to suggest that increasing dairy intake alone will significantly reduce the risk of cancer. On the other hand, fruits and vegetables are known to be rich in antioxidants and phytochemicals that have been associated with a reduced risk of cancer. Therefore, suggesting an increase in fruits and vegetables is a more evidence-based approach to reducing cancer risk.
Choice A rationale:
Encouraging exercise is a good recommendation for overall health, but it does not directly address the client's concern about reducing cancer risk. Focusing on a balanced diet, including plenty of fruits and vegetables, is more relevant to the client's specific concern.
Choice B rationale:
Reminding the client about Vitamin D-fortified dairy products may be helpful for addressing Vitamin D intake, but it doesn't necessarily address the broader concern of reducing cancer risk. Moreover, the link between dairy and cancer risk reduction is not as well-established as the benefits of fruits and vegetables.
Choice D rationale:
Providing information about cancer warning signs is important for cancer awareness but doesn't address the client's current dietary choices and concerns about cancer prevention. The focus should be on evidence-based dietary recommendations to reduce cancer risk.
Correct Answer is B
Explanation
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned correctly and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet is used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
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