The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?
Increased, strong
Diminished, weaker than expected
Absent, unable to palpate
Bounding
The Correct Answer is A
A. Increased, strong:
A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.
B. Diminished, weaker than expected:
This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.
C. Absent, unable to palpate:
If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.
D. Bounding:
A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wash the client’s face:
While washing the client's face might be part of general care, when specifically providing oral care for a client with dentures, the first step should be to don gloves to ensure infection control and safety.
B. Remove dentures:
Removing dentures may be a step in the oral care process, but it should come after donning gloves to maintain proper infection control measures.
C. Apply lubricant:
Applying lubricant might be necessary, especially if the client experiences dryness or discomfort, but it should follow the step of donning gloves.
D. Don gloves:
This is the first action because it is crucial to wear gloves before handling a client's dentures or engaging in any oral care procedures. Gloves protect both the nurse and the client from potential infections and ensure proper hygiene during care.
Correct Answer is D
Explanation
A. Every four hours:
Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.
B. Every hour:
Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.
C. Every shift:
Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.
D. Every two hours:
Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.
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