The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?
Instruct the UAP to report any abnormal findings.
Remind the UAP to check the client's pulse volume
Demonstrate the correct pulse site to the UAP
Confirm the accuracy of the pulse rate obtained by the UAP
The Correct Answer is C
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Ask the parents to explain what they understand about the child’s diagnosis.
Choice A rationale:
While it is important to support the parents’ decisions, this choice does not address the need for the parents to have accurate information about the condition and its potential complications.
Choice B rationale:
This statement is incorrect.Delaying surgery for hypospadias can lead to complications such as urinary problems, infections, and issues with sexual function later in life.
Choice C rationale:
This is misleading.Hypospadias does not typically resolve on its own, and waiting can result in complications that may require more complex surgical interventions.
Choice D rationale:
This choice is correct because it encourages the parents to share their understanding of the diagnosis, allowing the nurse to provide accurate information and address any misconceptions.This approach ensures that the parents make an informed decision based on a clear understanding of the condition and its implications.
Correct Answer is B
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
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