A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first?

Request assistance from a second nurse.

Count the client's apical pulse.

Check the client's pulse rate for 1 min.

Calculate the difference between the client's peripheral pulse and the client's apical pulse.

Answer and Explanation

The Correct Answer is A

A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.

C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.

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Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

A. Select a cuff that covers 50% of the client's upper arm. B. Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space. C. Elevate the client's arm above the level of the heart. D. Align the artery indicator on the blood pressure cuff with the client's brachial artery.

Correct Answer is D

Explanation

A: The cuff should ideally cover about 80% of the circumference of the upper arm, not just 50%.

B: The cuff should be placed level with the client's heart, specifically aligned with the brachial artery for accurate measurement.
C: Elevating the arm above the level of the heart can lead to an inaccurately low reading.
D: Proper alignment with the brachial artery ensures that the sensor correctly detects the arterial pressure, crucial for accurate readings.

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A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first?

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Naxlex Comprehensive Predictor Exams

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