A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?
Carotid
Popliteal
Radial
Apical
The Correct Answer is A
Choice A Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.
Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.
Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.
Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason: This is correct because placing ice to the bridge of the client’s nose can cause vasoconstriction and reduce blood flow to the nasal mucosa.
Choice B Reason: This is incorrect because tilting the client's head backward can cause blood to drain into the throat and increase the risk of aspiration, nausea, and vomiting.
Choice C Reason: This is correct because moving the client into high-Fowler position can lower the blood pressure in the head and neck and decrease bleeding.
Choice D reason Reason This is incorrect because instructing the client to blow his nose can dislodge any clots that have formed and worsen bleeding.
Choice E Reason: This is correct because applying pressure to the nares can compress the bleeding site and promote clotting.
Correct Answer is C
Explanation
Choice a) is incorrect because morphine sulfate is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that can relieve pain, anxiety, and dyspnea. Morphine sulfate can also reduce the preload and afterload of the heart, which can improve the cardiac output and oxygenation.
Choice b) is incorrect because laboratory testing of serum potassium is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that is important for the normal function of the cardiac cells and muscles. Serum potassium can be altered by various factors, such as renal function, acid-base balance, medications, or dietary intake. Serum potassium can affect the cardiac rhythm and contractility, which can influence the outcome of the client.
Choice c) is correct because 0.9% normal saline IV at 50 mL/hr continuous is a prescription that requires clarification for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that can maintain the fluid balance and blood pressure in the body. However, 0.9% normal saline can also cause fluid overload and worsen the heart failure symptoms, such as edema, crackles, and dyspnea. The nurse should clarify with the provider if this prescription is appropriate for the client's condition and if there are any parameters or limits for the fluid administration.
Choice d) is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that can increase the urine output and reduce the fluid volume and pressure in the body. Bumetanide can also decrease the preload and afterload of the heart, which can improve the cardiac output and oxygenation.
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