A nurse is assessing the pulse of a client and has difficulty feeling the pulse. What would she do next?
Record the pulse as "o" (zero) for that site.
Use a doppler device to locate and assess the pulse.
Come back in 15 minutes and reassess.
Report the finding to the physician.
The Correct Answer is B
A. Record the pulse as "0" (zero) for that site. A pulse should never be documented as absent without first using a Doppler device to confirm whether blood flow is present.
B. Use a Doppler device to locate and assess the pulse. If a pulse is difficult to palpate, a Doppler ultrasound should be used to detect blood flow before making any conclusions about circulation status.
C. Come back in 15 minutes and reassess. If the pulse is weak or difficult to locate, immediate assessment with a Doppler is needed instead of delaying evaluation.
D. Report the finding to the physician. While a physician should be notified if a pulse remains undetectable even with a Doppler, the nurse must first verify the absence of a pulse before escalating the concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.
Correct Answer is ["3"]
Explanation
Calculation:
To determine the number of capsules per dose, use the formula:
Capsules per dose = Dose ordered/ Dose available
Given:
- Ordered dose = 600 mg
- Available dose = 200 mg per capsule
Capsules per dose = 600mg/ (200mg/capsule)
= 3 capsules
Thus, the nurse will administer 3 capsules per dose.
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