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 A
Explanation
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Correct Answer is A
Explanation
Choice A rationale:
Pantoprazole is a proton pump inhibitor used to treat GERD by reducing stomach acid production. If the client reports not experiencing heartburn after eating lunch, it indicates that the medication is effectively reducing stomach acid and alleviating GERD symptoms.
Choice B rationale:
The ability to swallow food without difficulty is not directly related to the desired effect of pantoprazole. It may be an important aspect of the client's overall condition, but it does not specifically indicate the efficacy of the medication in treating GERD.
Choice C rationale:
Having no difficulty straining for a bowel movement is unrelated to the desired effect of pantoprazole in treating GERD. Pantoprazole does not directly influence bowel movements.
Choice D rationale:
Having a great appetite and feeling hungry are not relevant indicators of the effectiveness of pantoprazole in treating GERD. These statements are more related to the client's appetite and overall well-being rather than the response to the medication.
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