A nurse notes a client's pulse is a 2+ and understands this means what about the pulse?
The pulse is an expected finding.
The pulse is full volume and bounding.
The pulse is increased and strong.
The pulse is absent.
The Correct Answer is B
Choice A rationale:
A pulse rating of 2+ is not considered an expected finding. It indicates a weaker pulse, which requires further assessment.
Choice B rationale:
A pulse rated as 2+ means the pulse is full volume and bounding. In clinical practice, a 2+ pulse is considered normal and signifies a pulse that is easily palpable and has a normal strength. This is an essential finding for the nurse to understand because it reflects the circulatory status of the client. A 2+ pulse suggests adequate perfusion and a healthy heart pumping blood effectively.
Choice C rationale:
A pulse rating of increased and strong corresponds to a higher numeric value on the scale, indicating a stronger pulse. A 2+ pulse is not categorized as increased but is rather a moderate strength pulse.
Choice D rationale:
A pulse rating of 2+ does not suggest an absent pulse. An absent pulse would mean that no pulse can be felt, which is a critical situation requiring immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Keeping the walker at the end of the bed is inconvenient and increases the risk of falls. The walker should be easily accessible, ideally placed near where the client gets up from bed, to provide immediate support.
Choice B rationale: Fluorescent ceiling lights can be too harsh and cause glare, making it difficult for the client to see properly at night. Instead, using a nightlight or a softer, dimmable light source is recommended to provide safe, clear visibility.
Choice C rationale: Placing an area rug at the entry of the bathroom poses a tripping hazard. Loose rugs can easily shift and cause falls. It's better to use non-slip mats or secure carpeting to ensure safe footing, especially in areas prone to moisture.
Choice D rationale: Using a bath seat in the shower reduces the risk of slipping and falling. It provides a stable and secure place to sit while bathing, which is particularly important for clients with a history of falls or limited mobility.
Correct Answer is B
Explanation
Choice A rationale:
Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.
Choice B rationale:
Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.
Choice C rationale:
Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.
Choice D rationale:
Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.
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