A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the pedal pulses with a Doppler device

Assess the pedal pulses for a full minute

Assess the apical pulse with a Doppler device

Assess the apical pulse for a full minute

Answer and Explanation

The Correct Answer is D

A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.

B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.

C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.

D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.

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Correct Answer is A

Explanation

A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.

B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.

C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.

D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.

A. Determine the location of the pain. B. Reposition the client. C. Administer the medication. D. Review the effects of the pain medication.

Correct Answer is A

Explanation

A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.

B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.

C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.

D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.

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A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Nursing Test Bank

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