After noting that a client has a pulse deficit, what action should the nurse take next?
Instruct the client to report for weekly re-evaluations by the nurse.
Teach the client how to check pulses at home.
Report this finding to the physician.
Document this finding.
The Correct Answer is C
A. Instruct the client to report for weekly re-evaluations by the nurse. A pulse deficit indicates a difference between the apical and radial pulse rates, which may suggest cardiac dysfunction such as atrial fibrillation. This requires immediate evaluation, not just weekly monitoring.
B. Teach the client how to check pulses at home. While patient education is important, a pulse deficit is a clinical concern that should be addressed by a healthcare provider before self-monitoring is advised.
C. Report this finding to the physician. A pulse deficit may indicate arrhythmias or decreased cardiac output, requiring further evaluation and possible medical intervention. The physician should be informed promptly.
D. Document this finding. While documentation is necessary, the priority action is to report the pulse deficit to the physician so appropriate diagnostic tests and interventions can be initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An unconscious, intubated patient. An oral temperature is not appropriate for an unconscious or intubated patient due to the risk of injury and inability to follow instructions. A tympanic, rectal, or axillary method would be preferred.
B. A patient with bilateral middle ear infections. Tympanic thermometers measure temperature through the ear canal and tympanic membrane, which can be affected by infection or inflammation, leading to inaccurate readings. An oral or alternative method is preferred.
C. An agitated patient who cannot follow directions. Oral temperature requires cooperation, so it would not be suitable for an agitated patient who may bite or not keep the thermometer in place. A tympanic or axillary method would be better.
D. A patient with gastroenteritis who is vomiting. Vomiting can make oral temperature measurement uncomfortable and impractical. A tympanic, axillary, or rectal method would be more appropriate.
Correct Answer is ["1.5"]
Explanation
Calculation:
Volume to administer = Dose ordered/ Dose available
Given:
- Ordered dose = 75 mg
- Available concentration = 50 mg/mL
Volume = 75mg/ (50mg/mL)
= 1.5mL
Thus, the nurse will administer 1.5 mL.
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