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 D
Explanation
Choice A rationale
Asking which client is supposed to have medications compromises patient privacy and could lead to medication errors if an incorrect patient self-identifies. Proper patient identification is a fundamental safety measure, requiring objective verification to ensure the right medication is administered to the right patient.
Choice B rationale
Stating the patient's name and expecting a confirmation ("You are Mrs. Wilson, aren't you?") is a leading question and does not independently verify identity. A patient could respond affirmatively without truly being Mrs. Wilson, increasing the risk of medication errors by not adhering to objective verification protocols.
Choice C rationale
Asking if anyone knows Mrs. Wilson is an inappropriate and unprofessional method for patient identification. It breaches patient confidentiality and does not provide a reliable or direct means of verifying the intended recipient of medication, potentially leading to significant medication safety issues.
Choice D rationale
Checking the client's identification bracelets while the client states their name provides two independent identifiers, which is a standard and highly reliable method for patient identification. This dual verification minimizes the risk of medication errors by confirming both physical identification and the patient's verbal confirmation before administration.
Correct Answer is C
Explanation
Choice A rationale
While method of administration is crucial, controlled substance schedule and identification are not universally required on every prescription. The core components for safe and effective medication administration are paramount for all prescriptions.
Choice B rationale
This choice omits the method of administration, which is vital for safe and effective drug delivery. Without this information, there is a risk of administering the medication incorrectly, potentially leading to adverse effects or lack of therapeutic benefit.
Choice C rationale
A complete prescription scientifically requires the drug name for identification, the dose to ensure therapeutic effect and prevent toxicity, the method of administration for correct delivery route, and the prescriber's signature for legal authorization and accountability.
Choice D rationale
Controlled substance schedules are specific to certain medications and identification is not a standard universal requirement on all prescriptions. The core components for general medication administration are the drug name, dose, method, and prescriber signature.
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