A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

A. Auscultating lung sounds:

Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.

B. Obtaining the client’s temperature:

Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.

C. Assessing the strength of peripheral pulses:

Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.

D. Obtaining information about the client’s respirations:

Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.

E. Asking the client about a family history of any illness or disease:

Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.