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 ["2500"]
Explanation
Calculation:
To convert liters (L) to milliliters (mL), the conversion factor is:
1L = 1000mL
Given:
(2.5L×1000mL)/ 1L
= 2500mL
Thus, 2.5 L = 2500 mL.
Correct Answer is B
Explanation
A. Brachial artery. The brachial pulse is commonly used in infants but is not the best choice for assessing circulation in an unconscious adult.
B. Carotid artery. The carotid artery is the preferred site for assessing a pulse in an unconscious adult because it is a central pulse with strong circulation, even in low-perfusion states.
C. Radial artery. The radial pulse is a peripheral pulse and may be difficult to palpate if the patient has poor circulation or cardiac arrest. The carotid pulse is more reliable in emergencies.
D. Apical artery. There is no apical artery; the apical pulse is auscultated over the heart with a stethoscope and is not used in emergency pulse checks.
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