A 19-year-old client with a terminal illness has recently changed their code status to DNR. The nurse enters the room and finds the client pulseless. Which of the following actions should the nurse take?

Choice A rationale

Obtaining a daily weight is a standardized, non-invasive task that falls within the scope of practice for assistive personnel. In heart failure management, monitoring weight is crucial for assessing fluid volume status, where a gain of 2 to 3 pounds in a day or 5 pounds in a week is significant. The nurse remains responsible for interpreting the data and assessing for edema or respiratory distress, but the physical act of weighing is a delegated task.

Choice B rationale

Wound irrigation and dressing changes for a pressure injury require sterile or clean technique, assessment of tissue integrity, and clinical judgment regarding healing progress. These actions are within the professional scope of a licensed nurse and cannot be delegated to assistive personnel. The complexity of evaluating the wound bed for slough, eschar, or granulation tissue requires the advanced training of a registered nurse to ensure appropriate interventions and prevents potential complications or infection.

Choice C rationale

The administration of medications, including oral PRN pain medications, is a licensed nursing responsibility. It involves assessing the patient's pain level, verifying the five rights of medication administration, and monitoring for side effects or therapeutic outcomes. Assistive personnel are not licensed to handle or administer medications in most acute care settings. The nurse must evaluate the effectiveness of the medication and ensure that the dosage is safe based on the patient's current clinical status.

Choice D rationale

Teaching a client how to use an incentive spirometer is a core component of patient education and respiratory assessment. Education requires the nurse to evaluate the client's understanding, demonstrate the correct technique, and assess the client's ability to perform the task effectively to prevent atelectasis. Assistive personnel can encourage a client to use the device once the nurse has performed the initial teaching, but the actual instruction and validation of learning must be performed by the nurse.

Choice A rationale

The brachial pulse is located in the antecubital fossa and is primarily used for blood pressure measurement or assessing circulation in the infant. While it reflects systemic arterial pressure, it is not the standard peripheral site used for calculating a pulse deficit in adults. A pulse deficit occurs when the heart's contractions are too weak to transmit a palpable pressure wave to the periphery, and the radial artery is the conventional comparative site.

Choice B rationale

The dorsalis pedis pulse is found on the dorsal aspect of the foot and is used to evaluate peripheral vascular status in the lower extremities. Because of its significant distance from the heart, there is a natural delay and potential for dampened amplitude due to peripheral artery disease. It is not used for pulse deficit assessments because it does not provide a reliable immediate comparison to the central cardiac activity represented by the apical pulse.

Choice C rationale

A pulse deficit is determined by simultaneously measuring the apical pulse via auscultation and the radial pulse via palpation for one full minute. The radial artery is the most distal easily accessible site that should normally reflect every ventricular contraction. A difference between the apical and radial rates indicates that some cardiac contractions are not producing enough stroke volume to be felt peripherally, often seen in conditions like atrial fibrillation.

Choice D rationale

The carotid pulse is a central pulse located in the neck, reflecting pressure changes very close to the aorta. Because of its proximity to the heart, it is less likely to show a deficit compared to more distal peripheral sites. Using the carotid pulse would not accurately identify a pulse deficit because it usually remains palpable even when stroke volume is diminished, whereas the radial pulse would disappear, highlighting the discrepancy in perfusion.