A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
Femoral.
Popliteal.
Brachial.
Carotid.
The Correct Answer is B
Choice B rationale:
The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.
Choice A rationale:
Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.
Choice C rationale:
Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.
Choice D rationale:
Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Veracity refers to truthfulness and honesty in communication between the healthcare provider and the client. It involves providing accurate information and not deceiving the client. Discontinuing the experimental medication due to kidney failure demonstrates a commitment to the truth, but the primary ethical principle demonstrated here is nonmaleficence.
Choice B rationale:
Autonomy refers to respecting the client's right to make their own decisions about their healthcare. In this scenario, the medication was discontinued due to evidence of harm to the client's health. This action prioritizes the client's well-being over their autonomy to continue the treatment.
Choice C rationale:
Nonmaleficence, or the principle of "do no harm," is demonstrated in this scenario. The experimental medication was discontinued because it was causing rapidly advancing kidney failure. The healthcare provider's decision to stop the treatment is an example of prioritizing the client's safety and well-being by preventing further harm.
Choice D rationale:
Fidelity refers to being loyal, keeping promises, and maintaining trust in the nurse-client relationship. While this principle is important, it doesn't directly apply to the situation described, where the focus is on the ethical responsibility to prevent harm.
Correct Answer is C
Explanation
Choice A rationale:
Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.
Choice B rationale:
Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.
Choice C rationale:
This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.
Choice D rationale:
Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.
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