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 A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
Correct Answer is ["50.9"]
Explanation
Calculation:
To convert pounds to kilograms, use the formula:
Kg = lb/2.2
Substituting the given value:
Kg = 112.2/2.2
= 50.9kg
Thus, 112.2 lb = 50.9 kg.
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