The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

The use of two middle fingers lightly applied to area along the thumb side of the wrist.

Application of firm pressure on the wrist area along the side of the fifth digit.

Application of the bell of the stethoscope to the antecubital area of the upper extremity.

Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Answer and Explanation

The Correct Answer is A

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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Correct Answer is C

Explanation

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

A. Palpate for pitting edema. B. Assess for oral temperature. C. Inspect the oral mucosa. D. Auscultate adventitious lung sounds.

Correct Answer is C

Explanation

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

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The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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