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 D

Explanation

D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.

A. Refer the client for medical follow-up in two weeks. B. Document the benign findings. C. Perform a random blood sugar test per order. D. Ask the client about a family history of cancer.

Correct Answer is C

Explanation

A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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