A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

Pulse rhythm

Pulse deficit

C. Pulse amplitude

Pulse arrhythmia

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, Pulse amplitude. Pulse amplitude is a measure of the strength of the pulse and is rated on a 0-4 scale, with 0 indicating no pulse and 4 indicating a bounding pulse. A brisk pulse with a +2 rating suggests a normal pulse strength that is easily felt and is not weak or bounding. Pulse rhythm describes the regularity or irregularity of the pulse beats and is not related to pulse strength. Pulse deficit refers to the difference between the apical and radial pulse rates and is determined by auscultating the apical pulse while simultaneously palpating the radial pulse. Pulse arrhythmia refers to an irregular pulse rhythm.

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Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

A. Apply restraints to the hands or wrists to keep the patient in bed. B. Place a belt restraint on the client when they are sitting in a chair. C. Keep the bed in lowest position with all four side rails up. D. Educate the patient on using the call light and make sure the call light is within reach.

Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

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A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

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