A nurse is assessing a client who has atrial fibrillation.
Which of the following pulse characteristics should the nurse expect?

Not palpable.

Slow.

Irregular.

Bounding.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A pulse that is not palpable indicates severe circulatory collapse or cardiac arrest, not a characteristic of atrial fibrillation. It can be an emergency requiring immediate intervention.

Choice B rationale

A slow pulse, or bradycardia, is not a typical feature of atrial fibrillation. Bradycardia is often associated with conditions like hypothyroidism or beta-blocker therapy rather than atrial fibrillation.

Choice C rationale

Atrial fibrillation is characterized by an irregularly irregular pulse due to disorganized electrical activity in the atria, leading to inconsistent ventricular contractions. Pulse rate can vary widely.

Choice D rationale

A bounding pulse, which is strong and forceful, is typically associated with conditions like fever or hyperthyroidism rather than atrial fibrillation. Bounding pulses are not characteristic of atrial fibrillation.

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Correct Answer is A

Explanation

Choice A rationale

Assessing pulses in the affected arm ensures proper blood flow and identifies potential complications like arterial occlusion following cardiac catheterization. Monitoring for changes can prevent severe outcomes. Normal pulse rates: 60-100 bpm.

Choice B rationale

Keeping the client NPO post-procedure is unnecessary as food and liquids can typically be resumed once the patient is stable, unless specific medical instructions indicate otherwise.

Choice C rationale

Light pressure on the insertion site is insufficient for hemostasis. Firm pressure for 10-15 minutes is necessary to prevent bleeding and hematoma formation, especially in arterial catheterization sites.

Choice D rationale

Immediate ambulation post-cardiac catheterization risks bleeding and hematoma at the insertion site. Bed rest and activity restrictions should be maintained until hemostasis is confirmed, typically for 2-6 hours.

A. Administer O2 to maintain oxygen saturation greater than 90%. B. Prepare the client for intubation. C. Apply continuous ECG monitoring. D. Obtain the client’s family history.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationales:

Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.

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A nurse is assessing a client who has atrial fibrillation.Which of the following pulse characteristics should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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A nurse is assessing a client who has atrial fibrillation.
Which of the following pulse characteristics should the nurse expect?