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 ["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.
Correct Answer is A
Explanation
A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.
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