A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
Use the diaphragm of the stethoscope to listen to the apical pulsations
Count the apical pulsations for a full minute
Press the stethoscope firmly against the client's skin
Check the apical pulse with a Doppler device
The Correct Answer is B
Choice A reason: The diaphragm of the stethoscope is used for high-pitched sounds such as breath sounds, bowel, and normal heart sounds. For the apical pulse, which involves listening to the heart's sounds, the bell of the stethoscope is often recommended, especially for lower-pitched sounds like murmurs.
Choice B reason: Counting the apical pulsations for a full minute is the correct action when assessing the apical pulse, particularly for clients on cardiovascular medications. This ensures accuracy in detecting any irregularities or changes in the heart rate that could be affected by the medications.
Choice C reason: The stethoscope should be placed gently against the client's skin. Pressing too firmly can distort the heart sounds, making it difficult to accurately assess the apical pulse.
Choice D reason: A Doppler device is not typically used for routine assessment of the apical pulse. It is more commonly used when pulses are difficult to palpate or auscultate, such as in cases of peripheral arterial disease.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.
Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.
Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.
Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.
Correct Answer is D
Explanation
Choice A reason: Gloves are typically removed first because they are likely to be the most contaminated. They should be removed carefully to avoid contaminating the hands, using the glove-in-glove or beak method.
Choice B reason: The gown should be removed after the gloves because it may also be contaminated. The nurse should reach up to the shoulders and carefully pull the gown forward and away from the body, touching only the inside of the gown.
Choice C reason: Eyewear is removed after the gown. The nurse should handle the eyewear by the arms, avoiding touching the front part that has been exposed to contaminants.
Choice D reason: The mask should be removed last because it protects the mucous membranes of the mouth and nose from infectious droplets. It should be taken off by handling the ties or elastic bands from behind the head and pulling it away from the face without touching the front of the mask.
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