The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?
Thready pulse volume.
Missing pulse.
Light pressure applied to pulse.
Pulse skips beats.
The Correct Answer is A
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
B. A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
C. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
D. Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B rationale:
The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.
Choice C rationale:
Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.
Choice D rationale:
The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is moreappropriate for this purpose.
Correct Answer is B
Explanation
This is the best intervention for the PN to implement because it relieves the muscle spasm and reduces the pain of a leg cramp. Leg cramps are common during pregnancy and labor due to changes in calcium levels, fluid balance, or pressure on nerves and blood vessels.
A. Massaging the calf and foot is not recommended because it may increase pain or cause injury to the muscle or nerve.
C. Checking the pedal pulse in the affected leg is not necessary unless there is a suspicion of vascular compromise or thrombosis, which are unlikely causes of a leg cramp.
D. Elevating the leg above the heart is not helpful because it may impair blood flow or increase pressure on the nerve or muscle.
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