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 C

Explanation

The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.

A. Chest B. Perineal area C. Face D. Feet

Correct Answer is C

Explanation

The correct answer is choice C, face. When beginning a complete bed bath, the nurse should first wash the client's face, followed by the arms, chest, abdomen, legs, perineal area, back, and then feet. Washing the face first is important to promote client comfort and hygiene, and also sets a positive tone for the rest of the bath. Additionally, washing the face before the perineal area helps to prevent cross-contamination of bacteria from the perineal area to the face.

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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 performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

Correct Answer is C

Explanation

A nurse is beginning a complete bed bath for a client. After preparing the client by removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?

Correct Answer is C

Explanation

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