The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?

Check the reading after the other nurse leaves the room.

Document a pulse deficit of 16 beats per minute.

Report the results of the deficit to the healthcare provider.

Repeat the assessment to obtain another reading.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Checking the reading after the other nurse leaves the room is inappropriate. This option suggests waiting until the other nurse leaves to check the reading again. However, there's no guarantee that the discrepancy will resolve itself, and waiting might delay necessary intervention if there is indeed a pulse deficit. Therefore, this option does not address the immediate need for clarification.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is inappropriate. While there appears to be a difference between the apical and radial pulse readings, it's important to verify the accuracy of the measurements before documenting a pulse deficit. Documenting without confirmation could lead to inaccurate information in the patient's medical record.
Choice C Reason:
Reporting the results to the healthcare provider without confirming the accuracy of the measurements may lead to unnecessary concern or intervention. It's essential to ensure that the findings are accurate before reporting them to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is appropriate. This option prioritizes patient safety by acknowledging the need to confirm the accuracy of the measurements. Repeating the assessment allows the nurses to ensure consistency and reliability in their findings before taking further action or reporting to the healthcare provider.
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Correct Answer is A

Explanation

Choice A Reason:
Observing pupil size when focusing on a near object and then a far object is correct. This choice is correct because it directly assesses the pupillary reaction to accommodation, which refers to the changes in pupil size that occur when the eyes shift focus between near and far objects. Observing the pupils while the client focuses on a near object and then a far object allows the nurse to assess how the pupils constrict (become smaller) or dilate (become larger) in response to changes in focus, providing valuable information about the client's accommodation reflex.
Choice B Reason:
Comparing the shape of each of the pupils bilaterally with normal room light is incorrect. While comparing the shape of each pupil bilaterally with normal room light is a valid assessment technique for evaluating pupillary size and symmetry, it does not specifically assess the pupillary reaction to accommodation. Therefore, this choice is not as directly relevant to assessing accommodation reflex as choice A.
Choice C Reason:
Noting the speed of pupil constriction when a penlight is shined into the eye is incorrect. This choice refers to assessing the pupillary light reflex, which involves observing the speed and extent of pupil constriction in response to a bright light stimulus. While this assessment is important for evaluating the pupillary response to light, it does not specifically assess accommodation, which involves changes in pupil size in response to changes in focus between near and far objects. Therefore, this choice is not directly relevant to assessing accommodation reflex.
Choice D Reason:
Determining if dilation of the pupils occurs when the room is darkened is incorrect. This choice involves assessing the pupillary response to changes in ambient light levels, which is known as the pupillary light reflex. While assessing pupil dilation in response to darkness is important for evaluating the pupillary response to changes in light, it does not specifically assess accommodation reflex. Therefore, this choice is not directly relevant to assessing accommodation reflex.

A. Hyperactive bowel sounds. B. A minor variation. C. Normal borborygmic sounds. D. Possible renal artery stenosis.

Correct Answer is D

Explanation

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

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The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?

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Naxlex Comprehensive Predictor Exams

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Correct Answer is A

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is D

Explanation

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

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