A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

Carotid bruit

Heart murmur

Pulse deficit

Bounding radial pulse

Answer and Explanation

The Correct Answer is C

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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Correct Answer is A

Explanation

A. "I should apply clean dressings over the top of blood-saturated dressings and hold pressure.” This prevents disruption of clot formation and controls bleeding.

B. "I can clean wounds with hydrogen peroxide.” Hydrogen peroxide can damage healthy tissue and delay healing.

C. "I can carefully remove the object from a penetrating wound.” Objects should be left in place until medical professionals remove them.

D. "I should place the affected area in a dependent position.” Elevating an injured limb helps reduce swelling and bleeding.

A. A stand assist lift B. A footboard C. A slide board D. A mechanical lift with a full body sling

Correct Answer is A

Explanation

A. A stand assist lift: A stand assist lift is appropriate for clients who can bear some weight and have upper body strength. It provides support during the transfer while allowing the client to participate in the movement, promoting mobility and independence.

B. A footboard: A footboard is used to prevent foot drop in bedridden clients and is not a transfer device. It does not assist with movement from a chair to a bed.

C. A slide board: A slide board is typically used for clients who have good upper body strength but cannot bear weight on their legs, such as paraplegic clients. Since this client can bear partial weight, a slide board is not the best option.

D. A mechanical lift with a full-body sling: A full-body sling mechanical lift is used for clients who cannot bear weight and have minimal or no upper body strength. Since this client can bear some weight and has upper body strength, a stand assist lift is the more appropriate choice.

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

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