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:
- 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.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- 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.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Assign the remainder of medication administration to another PN who is performing treatments.
Choice A rationale:
Asking unlicensed assistive personnel (UAP) to give medications to their assigned residents is not the best action to take in this situation. Medication administration requires a certain level of training and knowledge to ensure safe and accurate delivery. UAPs may not have the appropriate training and legal authorization to administer medications, which could lead to potential errors and harm to the residents.
Choice B rationale:
Documenting why all the medications were not given to each resident is not sufficient to address the issue at hand. While documentation is essential for record-keeping and communication, it does not resolve the problem of medication administration being left incomplete. The priority should be finding a qualified person to administer the remaining medications.
Choice C rationale:
This is the correct answer because assigning the remainder of medication administration to another PN who is performing treatments ensures that qualified and trained personnel are handling the medication administration. This PN is likely familiar with medication protocols and safety measures, reducing the risk of errors.
Choice D rationale:
Denying the medication aide's request to leave before all medications are given might not be practical if the aide is genuinely unwell or unable to continue working safely. The focus should be on ensuring that medication administration is completed by qualified staff rather than forcing the sick aide to stay.
Correct Answer is ["0.6"]
Explanation
Step 1: The medication is prescribed as 30 mg every 12 hours, which means it is given twice a day. So, the total daily dosage in mg is 30 mg × 2 = 60 mg.
Step 2: The medication is available in 30 mg per 0.3 mL. So, to find out how many mL correspond to 60 mg, we set up a proportion: (30 mg / 0.3 mL) = (60 mg / x mL). Solving for x gives x = (0.3 mL / 30 mg) × 60 mg = 0.6 mL.
Therefore, the practical nurse should administer 0.6 mL of the medication each day.
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