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
Asses the apical pulse with a doppler device
Assess the apical pulse for a full minute
Assess the pedal pulses for a full minute
The Correct Answer is C
A. Assess the pedal pulses with a Doppler device:
Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.
B. Assess the apical pulse with a Doppler device:
While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.
C. Assess the apical pulse for a full minute:
This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.
D. Assess the pedal pulses for a full minute:
While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Do you want to talk about your health concerns?"
While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.
B. "Would it help to discuss your feelings about this hospitalization?"
This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.
C. "Would you tell me about all of your medical issues?"
This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.
D. "What brought you to the hospital?"
This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.
Correct Answer is A
Explanation
A. Assess the client.
This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.
B. Notify the nurse manager.
Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.
C. Complete an incident report.
After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.
D. Call the client’s provider.
If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.
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