The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+". The nurse recognizes that this reading indicates what type of pulse?
Absent.
Bounding.
Weak.
Normal.
The Correct Answer is D
Choice A rationale
An absent pulse (0) indicates no palpable pulsation, often due to an occlusion or severe vasoconstriction. This signifies a complete lack of blood flow through the vessel, requiring immediate medical attention to prevent tissue ischemia and necrosis.
Choice B rationale
A bounding pulse (4+) is characterized by a strong, easily palpable pulsation that is not easily obliterated by pressure. This can indicate conditions like fluid overload, hypertension, or hyperkinetic states, reflecting increased stroke volume or decreased peripheral resistance.
Choice C rationale
A weak pulse (1+) is characterized by a faint, barely palpable pulsation that is easily obliterated by pressure. This can be indicative of decreased stroke volume, hypovolemia, or peripheral artery disease, signifying reduced blood flow and perfusion.
Choice D rationale
A normal pulse (2+) is characterized by a readily palpable pulsation that is easily discernible and not easily obliterated by pressure. This finding indicates adequate cardiac output and peripheral perfusion, signifying healthy cardiovascular function within normal physiological parameters.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Albuterol is a selective beta-2 adrenergic agonist. Its primary action is bronchodilation by stimulating beta-2 receptors in the bronchial smooth muscle, leading to relaxation and widening of the airways. It does not directly suppress the cough reflex, which is a protective mechanism to clear airways. Cough suppression is typically achieved by antitussive medications acting on the central nervous system or peripheral cough receptors.
Choice B rationale
Albuterol is a short-acting beta-agonist (SABA), characterized by a rapid onset of action and relatively short duration (4-6 hours). Therefore, it is used for immediate relief of bronchospasm and acute symptoms of asthma, not for long-term daily maintenance. Long-term maintenance medications include inhaled corticosteroids or long-acting beta-agonists (LABAs) used consistently to control inflammation and prevent exacerbations.
Choice C rationale
Albuterol's rapid onset of action and potent bronchodilatory effects make it the ideal medication for acute relief of bronchospasm in asthma. It is used as a "rescue" inhaler to quickly open airways during an asthma attack or before exercise to prevent exercise-induced bronchospasm. This immediate effect is crucial for alleviating respiratory distress.
Choice D rationale
Post-tussive emesis, or vomiting after coughing, is often a symptom of severe coughing spells. While albuterol can alleviate coughing by reducing bronchospasm, its primary mechanism is not to prevent emesis directly. Emesis is a gastrointestinal reflex; albuterol's action is primarily on the respiratory system. Addressing the underlying cause of severe coughing would indirectly reduce emesis.
Correct Answer is B
Explanation
Choice A rationale
A 15-degree angle is typically used for intradermal injections, where the medication is deposited just beneath the epidermis to form a bleb, not for subcutaneous injections which target the adipose tissue layer. Taut skin is also incorrect for subcutaneous.
Choice B rationale
For an average-sized client receiving a subcutaneous injection, a 45-degree angle facilitates optimal medication deposition into the subcutaneous adipose tissue layer. Pinching the skin helps to elevate the subcutaneous tissue away from underlying muscle, reducing the risk of intramuscular injection.
Choice C rationale
A 90-degree angle is typically used for intramuscular injections in most adults, aiming to deposit medication deep into muscle tissue. Stretching the skin is generally more appropriate for intramuscular injections rather than subcutaneous.
Choice D rationale
Z-tracking is a technique primarily used for intramuscular injections of irritating medications to prevent leakage back into subcutaneous tissue. It is not a standard technique for subcutaneous injections, which use a different angle and skin manipulation.
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