A nurse is assisting in the care of a client who has developed cardiogenic shock.

Which pulse site should the nurse use when assessing circulation to the client’s brain?

Femoral

Radial

Carotid

Popliteal

Answer and Explanation

The Correct Answer is C

Choice A rationale
The femoral pulse is located in the groin area and is often used during procedures or when other pulse sites are not available. It does not directly assess circulation to the brain.
Choice B rationale
The radial pulse, located on the thumb side of the wrist, is commonly used to measure heart rate but does not directly assess circulation to the brain.
Choice C rationale
The carotid pulse is located on either side of the neck below the jawline. It is one of the major arteries that supply blood to the brain. In an emergency, this pulse site is used to assess circulation to the brain.
Choice D rationale
The popliteal pulse is located behind the knee and is used to assess circulation to the lower leg. It does not directly assess circulation to the brain.

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Correct Answer is B

Explanation

Choice A rationale
Changing the ostomy pouch daily is not necessary and can lead to skin irritation. The pouch should be changed every 2-4 days or as directed by the healthcare provider.
Choice B rationale
The ostomy pouch should be emptied when it is 1/3 to 1/2 full to prevent leakage and skin irritation.
Choice C rationale
Trimming the opening of the ostomy seal to be 1/2 in. wider than the stoma is incorrect. The opening should be just slightly larger than the stoma to prevent skin irritation.
Choice D rationale
Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended as it can interfere with the adhesion of the pouch.

A. Areas around pins are dry. B. Crusts around pins. C. Purulent drainage around pins. D. Absence of pain at the site.

Correct Answer is C

Explanation

Choice A rationale
Areas around pins being dry is a normal finding and does not need to be reported.
Choice B rationale
Crusts around pins are also a normal finding as they are usually dried exudate and do not indicate an infection.
Choice C rationale
Purulent drainage around pins is a sign of infection. This should be reported to the unit care coordinator immediately as it may require antibiotic treatment.
Choice D rationale
Absence of pain at the site is a normal finding and does not need to be reported.

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A nurse is assisting in the care of a client who has developed cardiogenic shock. Which pulse site should the nurse use when assessing circulation to the client’s brain?

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A nurse is assisting in the care of a client who has developed cardiogenic shock.

Which pulse site should the nurse use when assessing circulation to the client’s brain?