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 C
Explanation
A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.
B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.
C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Aging leads to arteriosclerosis, where blood vessels become stiffer, reducing their ability to expand and contract, which contributes to increased systolic blood pressure. This is a well-documented normal physiologic change in older adults.
D. Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.
Correct Answer is D
Explanation
A. "Don't worry. The cancer prevents you from becoming addicted." This statement is incorrect because having cancer does not prevent addiction. However, appropriate pain management in patients with severe pain does not typically lead to addiction.
B. "That is a valid worry. I wouldn't want to become addicted." While acknowledging the patient’s concern is important, this response reinforces fear rather than providing reassurance based on medical evidence.
C. "My cousin was addicted to pain killers when he had cancer." This response is inappropriate because it is anecdotal and does not address the patient’s concern with factual medical information.
D. "Because you have severe pain, the medication is necessary. There is little chance of addiction as long as you take the medication as prescribed." This is the best response because it reassures the patient that pain control is a priority and that, when used correctly, the risk of addiction is minimal.
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