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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
Correct Answer is A
Explanation
A. Cleaning and drying the area before applying the patch is essential to ensure proper adhesion and effectiveness of the medication. This statement indicates the client understands proper application procedures.
B. Using lotion on irritated skin before applying a new patch can interfere with the patch's ability to adhere and may affect medication absorption. Therefore, this statement indicates a lack of understanding.
C. Removing the old patch and applying a new one in the same location is generally not recommended because it can lead to skin irritation and decreased absorption. This indicates a misunderstanding of proper patch rotation.
D. While pressing the patch securely is important, it is not as critical as ensuring the skin is clean and dry before application. Thus, this statement alone does not indicate full understanding of the teaching.
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