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 B
Explanation
Choice A rationale:
The anterior surface of the drape is not the correct choice because it includes the central sterile area, which should never be touched by the nurse. Touching the central sterile area contaminates the field.
Choice B rationale:
The outer 1-inch border of the drape is the correct choice for the nurse to touch. This border is considered non-sterile and can be handled without contaminating the sterile field. It acts as a barrier, preventing contaminants from reaching the central sterile area.
Choice C rationale:
The top inner corners of the drape are part of the central sterile area and should not be touched by the nurse. Touching this area would contaminate the sterile field.
Choice D rationale:
The posterior aspect of the drape is not the correct choice because it is part of the central sterile area. Touching this area would contaminate the sterile field. When preparing a sterile field, it is essential for the nurse to follow strict aseptic techniques to maintain the sterility of the field. This includes touching only the designated non-sterile areas, such as the outer 1-inch border of the sterile drape, to avoid contamination.
Correct Answer is D
Explanation
Choice A rationale:
Ears are located on the sides of the head, not between the cranial and thoracic cavities. The ears are lateral structures on the head.
Choice B rationale:
Elbow is a joint located in the upper limb, specifically in the arm. It is not between the cranial and thoracic cavities. The elbow is a joint that allows the forearm to bend.
Choice C rationale:
Knee is a joint in the lower limb, connecting the thigh bone to the shin bone. It is not located between the cranial and thoracic cavities. The knee joint allows for movements like bending and straightening of the leg.
Choice D rationale:
The nape of the neck refers to the back of the neck. It is the posterior part of the neck, located between the cranial (head) and thoracic (upper chest) cavities. The nape of the neck is a specific anatomical location.
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