A nurse is caring for a client who has a dysrhythmia. Which of the following techniques is appropriate for the nurse to use to assess for a pulse deficit?
Obtain apical and radial rates simultaneously.
Palpate pulses in the lower extremities.
Check blood pressure in left and right arms.
Compare the pulse strength in upper extremities.
The Correct Answer is A
A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).
B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.
C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Controlled substances typically require a licensed nurse or provider to witness the wasting, not assistive personnel.
B. Wasted medication should be disposed of according to facility policies but not necessarily in a sharps container unless it is a sharp object.
C. Recording the amount of medication wasted on the controlled substance inventory record is a crucial step to maintain accurate documentation.
D. Returning the unused portion of a controlled substance to the pharmacy is not an appropriate action and goes against medication safety protocols. Controlled substances should be wasted and documented properly.
Correct Answer is D
Explanation
A. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.
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