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
Choice A rationale:
Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.
Choice B rationale:
While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.
Choice C rationale:
Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.
Choice D rationale:
Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.
Correct Answer is ["D"]
Explanation
Choice A rationale:
Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.
Choice B rationale:
Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.
Choice C rationale:
Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.
Choice D rationale:
Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.
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