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 C
Explanation
Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.
Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.
Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.
Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because soaking the crusted areas of tape with adhesive remover is not the best approach to change nasogastric tube tape that has become crusted with secretions. Adhesive remover is a solvent that can dissolve the glue that holds the tape to the skin. However, it can also irritate the skin and cause redness, burning, or allergic reactions. The nurse should avoid using adhesive remover on the patient's face, especially near the eyes, nose, or mouth.
Choice B reason: This is an incorrect choice because saturating the tape with a denatured alcohol solution is not the best approach to change nasogastric tube tape that has become crusted with secretions. Denatured alcohol is a mixture of ethanol and other chemicals that can dissolve the glue that holds the tape to the skin. However, it can also dry out the skin and cause cracking, peeling, or bleeding. The nurse should avoid using denatured alcohol on the patient's face, especially near the eyes, nose, or mouth.
Choice C reason: This is an incorrect choice because using blunt-edged scissors to loosen the tape from the skin is not the best approach to change nasogastric tube tape that has become crusted with secretions. Blunt-edged scissors are scissors that have rounded tips instead of sharp points. They can be used to cut the tape without injuring the skin. However, they can also pull or tug on the skin and cause pain, discomfort, or damage. The nurse should avoid using scissors on the patient's face, especially near the eyes, nose, or mouth.
Choice D reason: This is the correct choice because softening the secretions using a warm moist washcloth is the best approach to change nasogastric tube tape that has become crusted with secretions. A warm moist washcloth is a cloth that is soaked in warm water and wrung out. It can be applied gently to the crusted areas of tape to soften the secretions and loosen the tape from the skin. It can also soothe the skin and prevent irritation or infection. The nurse should use a clean washcloth for each application and discard it after use.
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