During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Wait until the end of the physical assessment to reassess the radial pulse.

Reassess the client's pedal pulse on the other foot.

Assess the client's 51 and 52 sounds for regularity.

Assess the client's apical pulse for a full minute.

Answer and Explanation

Correct Answer : A,D

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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Correct Answer is A

Explanation

A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.

B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.

C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.

D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.

A. Subjective B. Tertiary C. Secondary D. Primary

Correct Answer is C

Explanation

A. Subjective: Subjective data refers to information reported by the patient directly, which is not applicable in this case since the client cannot communicate.

B. Tertiary: This term is not commonly used in the context of data sources in health assessments.

C. Secondary: Secondary data is information provided by someone other than the patient, such as a family member or caregiver, which is applicable here since the daughter is providing the information.

D. Primary: Primary data is directly obtained from the patient, not from a secondary source like the daughter.

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During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

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