The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

Carotid

Apical

Radial

Brachial

Answer and Explanation

The Correct Answer is A

Choice A reason: The carotid pulse is used for unresponsive, non-breathing patients, as it is the most reliable central pulse, reflecting cardiac output during cardiac arrest. Its accessibility and strength make it ideal for rapid assessment, guiding CPR initiation, per ACLS and emergency assessment protocols.

Choice B reason: The apical pulse, assessed via auscultation, is impractical for an unresponsive, non-breathing patient, requiring time and equipment. In emergencies, the carotid pulse is faster and more reliable to confirm pulselessness, ensuring timely CPR, per cardiac arrest management guidelines.

Choice C reason: The radial pulse is peripheral and less reliable in cardiac arrest, as it may be absent due to poor perfusion. The carotid pulse better reflects central circulation, critical for assessing unresponsiveness and apnea, guiding immediate resuscitation efforts, per emergency care standards.

Choice D reason: The brachial pulse is used in infants or for blood pressure but is less accessible than the carotid in adults during arrest. The carotid provides a quick, reliable pulse check, ensuring rapid initiation of life-saving measures, per ACLS and pulse assessment protocols.

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Correct Answer is C

Explanation

Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.

Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.

Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.

Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.

A. Protecting clients from a health care provider under the influence of an opioid. B. Performing dressing changes to promote wound healing. C. Providing emotional support to clients who are anxious. D. Administering pain medications to a client in pain.

Correct Answer is A

Explanation

Choice A reason: Nonmaleficence, “do no harm,” is exemplified by protecting clients from an impaired provider, whose opioid use could lead to errors or unsafe care. This action prevents harm, prioritizing patient safety, and aligns with ethical principles of nursing, per professional standards and patient advocacy.

Choice B reason: Performing dressing changes promotes healing, an act of beneficence (doing good), not nonmaleficence. While it prevents infection, the primary intent is therapeutic benefit, not harm prevention, making it less aligned with nonmaleficence’s focus on avoiding harm, per nursing ethics.

Choice C reason: Providing emotional support is beneficence, as it actively benefits the client’s well-being. Nonmaleficence focuses on preventing harm, not promoting positive outcomes. Support reduces anxiety but does not directly address harm avoidance, making it incorrect for nonmaleficence, per ethical principles in nursing.

Choice D reason: Administering pain medication is beneficence, relieving suffering to improve comfort. Nonmaleficence involves avoiding harm, not providing therapeutic relief. While safe administration prevents harm, the primary goal is pain relief, not harm prevention, per nursing ethics and pharmacological care principles.

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The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?

Correct Answer is C

Explanation

Which is an example of nonmaleficence?

Correct Answer is A

Explanation

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