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 ["B","D","E"]

Explanation

A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.

B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.

C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.

D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.

E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.

A. Peanuts B. Chicken C. Yams D. Eggs

Correct Answer is B

Explanation

A. Peanuts contain protein but also have a higher fat content, making them less optimal compared to lean meats.

B. Chicken is an excellent source of high-quality protein, providing essential amino acids with lower fat content, making it the best recommendation among the options listed.

C. Yams are primarily a carbohydrate source and do not significantly contribute to protein intake.

D. Eggs are a good source of protein, but chicken typically provides more protein per serving, making it the superior choice for increasing protein intake.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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