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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.
Correct Answer is B
Explanation
A. Check the patient's apical rate to check for a pulse deficit. While an apical pulse assessment may be useful later, the priority in a sudden drop in blood pressure with signs of fainting is to ensure adequate circulation by checking a central pulse.
B. Immediately check the client's carotid pulse. A significant blood pressure drop (132/82 to 104/52), pale skin, and signs of fainting suggest possible shock or circulatory collapse. The carotid pulse should be checked immediately to assess perfusion.
C. Elevate the head of the patient's bed to at least 45 degrees. Raising the head of the bed could worsen hypotension and decrease blood flow to the brain, increasing the risk of syncope. The Trendelenburg position or lying flat may be more appropriate.
D. Report the findings to the health care provider immediately. While the provider should be notified, the priority action is to assess circulation by checking the carotid pulse first before escalating care.
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