The nurse is informed during shift report that a client has a wide pulse pressure, is hypertensive, and has a pulse deficit. When the nurse enters the client's room, which assessments should the nurse perform in order to confirm this report?
1. Blood pressure and apical pulse assessments
2. Blood pressure and radial pulse assessment
3. Blood pressure and respiratory rate assessment
4. Blood pressure and radial-apical pulse assessment
4
Rationale 1: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.
Rationale 2: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.
Rationale 3: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.
Rationale 4: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.
Global Rationale: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.
You might also like to view...
The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?
A) Lung fields B) Voiding C) Joint pain D) Mentation
During a preoperative assessment, the nurse learns that a client takes all-natural nutritional supplements. Which response should the nurse make to this client?
a. "Discuss this with the anesthesiologist the day of surgery." b. "Skip the supplements the day of surgery, but resume afterwards." c. "Since the dietary supplements are "all natural" there should not be a problem." d. "Even all-natural dietary supplements may interact with anesthesia, medications, or alter blood clotting."
A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant?
A) Observing for excessive crying B) Auscultating for a cardiac murmur C) Assessing for the presence of femoral pulses D) Recording an upper extremity blood pressure
When conducting interviews using Leininger's theory as a guide, researchers listen to ______________ to understand an informant's views, beliefs, and practices
A. Informed sources B. Key informants C. General informants D. Subject informants