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

Measure the client's apical pulse while another nurse measures their radial pulse.

After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse.

Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min.

Assess both of the client's radial pulses at the same time and compare the quality of pulsations.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.

B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.

C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.

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Correct Answer is B

Explanation

Rationale:

A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.

B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.

C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.

A. Pain level of 1 on a scale of 0 to 10 B. Capillary refill time 1 second C. BMI 35 D. Oxygen saturation 97% on room air

Correct Answer is C

Explanation

Rationale:

A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.

B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.

C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.

D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.

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