The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?
Document the finding in the patient’s medical record.
Assess the brachial pulse for a pulse deficit.
Notify the health care provider immediately.
Count the patient’s apical pulse for one full minute.
The Correct Answer is D
Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.
Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.
Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.
Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: This is a correct choice because autonomy is a key element of decentralized decision making. Autonomy refers to the ability and right of individuals or groups to make their own decisions without interference from others. Decentralized decision making empowers the employees to exercise their autonomy and use their own judgment and expertise to solve problems and improve performance².
Choice B reason: This is a correct choice because authority is a key element of decentralized decision making. Authority refers to the power and legitimacy to make decisions and take actions. Decentralized decision making delegates the authority from the top management to the lower levels of the organization, allowing them to make decisions that affect their work and outcomes².
Choice C reason: This is an incorrect choice because prioritization is not a key element of decentralized decision making. Prioritization refers to the process of ranking tasks or goals according to their importance and urgency. Decentralized decision making does not necessarily involve prioritization, as different individuals or groups may have different criteria and preferences for setting their priorities².
Choice D reason: This is a correct choice because responsibility is a key element of decentralized decision making. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. Decentralized decision making assigns the responsibility to the individuals or groups who make the decisions and hold them accountable for their actions and outcomes².
Choice E reason: This is a correct choice because accountability is a key element of decentralized decision making. Accountability refers to the expectation and requirement to report and explain the decisions and actions taken and the results achieved. Decentralized decision making ensures that the individuals or groups who make the decisions are accountable for their performance and quality, and that they receive feedback and recognition for their work².
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because gently trimming the patient’s toenails after soaking the feet in warm soapy water is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Trimming the toenails can be risky for the diabetic patient, as it can cause bleeding, infection, or injury to the nail bed or surrounding skin. The nurse should avoid cutting the toenails of the diabetic patient, unless instructed by a podiatrist.
Choice B reason: This is an incorrect choice because using a pumice stone to smooth roughened areas of skin on the patient’s feet is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A pumice stone is a porous rock that can be used to exfoliate the skin and remove dead cells. However, it can also damage the skin and cause abrasions, irritation, or infection. The nurse should be careful when using a pumice stone on the diabetic patient, and avoid rubbing too hard or too often.
Choice C reason: This is an incorrect choice because liberally applying lotion to the patient's feet especially between the toes is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Applying lotion to the feet can help to moisturize and soften the skin, but it can also create a moist environment that can promote fungal growth and infection. The nurse should apply lotion sparingly to the feet of the diabetic patient, and avoid applying it between the toes.
Choice D reason: This is the correct choice because obtaining a consultation for a podiatrist to assess the feet and provide nail care is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A podiatrist is a specialist who can diagnose and treat foot problems, such as nail disorders, skin conditions, or infections. The podiatrist can safely and effectively trim the toenails of the diabetic patient, and provide education and advice on foot care and prevention of complications. The nurse should refer the diabetic patient to a podiatrist at least once a year, or more often if needed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.