A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?
Count the client's radial and apical pulses simultaneously with another nurse.
Calculate the client's pulse for 30 seconds and multiply by 2.
Assist the client to a side-lying position.
Auscultate the area of the client's chest over the Erb's point.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Count the client's radial and apical pulses simultaneously with another nurse. Rationale: In the presence of an irregular heart rate, a pulse deficit might indicate a discrepancy between the peripheral (radial) and central (apical) pulses. Counting the pulses simultaneously with another nurse helps to accurately assess this deficit. By comparing the two pulse rates, the nurse can identify if there is a difference, which might indicate inadequate circulation or irregular heartbeats that aren't effectively transmitting to the peripheral arteries.
Choice B rationale:
Calculate the client's pulse for 30 seconds and multiply by 2. Rationale: While calculating the pulse rate for 30 seconds and then multiplying by 2 is a valid method to determine the heart rate, it doesn't address the specific concern of a pulse deficit. This approach might help in assessing the overall heart rate but doesn't provide information about potential irregularities or discrepancies between peripheral and central pulses.
Choice C rationale:
Assist the client to a side-lying position. Rationale: Assisting the client to a side-lying position doesn't directly relate to the assessment of a pulse deficit. The position of the client wouldn't significantly impact the assessment of irregular heart rates or pulse deficits.
Choice D rationale:
Auscultate the area of the client's chest over the Erb's point. Rationale: Auscultating the area of the client's chest over the Erb's point is a technique used to assess heart sounds, particularly the S2 heart sound. This technique is not relevant to assessing a pulse deficit. It can provide information about heart valve function but doesn't help in evaluating a discrepancy between peripheral and central pulses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: A thready pulse.
Choice A rationale:
BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.
Choice B rationale:
A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.
Choice C rationale:
Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.
Choice D rationale:
Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.
Correct Answer is D
Explanation
The correct answer is choice D: "Provide mouth care to them at least every 2 hours."
Choice A rationale:
Encouraging meals at least three times daily is not appropriate for a client who is near death. As clients approach the end of life, their appetite often decreases, and they may be unable to tolerate regular meals. It's more important to focus on providing comfort and relief.
Choice B rationale:
Keeping the room warm to help them breathe easier is not necessarily true. While a comfortable room temperature can be important for the client's overall comfort, warmth alone does not significantly impact breathing in the context of impending death. Breathing difficulties at this stage are usually related to physiological changes rather than room temperature.
Choice C rationale:
Helping the client onto their left side if they are experiencing nausea is not a universally applicable instruction. While left-side positioning can help alleviate nausea for some clients, it might not be suitable for everyone. Nausea can be caused by various factors, and the caregiver should assess the client's comfort and preferences before changing their position.
Choice D rationale:
Providing mouth care to the client at least every 2 hours is the most appropriate instruction among the choices. Near the end of life, many clients become less able to maintain their oral hygiene due to various factors, including weakness and reduced consciousness. This can lead to discomfort and potential complications. Regular mouth care helps keep the client's mouth moist and clean, enhancing their overall comfort.
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