The nurse is assessing a client who is in shock and has an abnormal pulse rate. What is the most important technique for the nurse to use when assessing a client's carotid pulse?

Question

A) Avoid reaching across the client's neck to count the pulse.
B) Count the pulse beats for 30 seconds.
C) Use the first finger to check the pulse.
D) Assess both carotid pulses simultaneously.

Answer 1

A
Feedback:
The nurse should not reach across the client's neck to count the carotid pulse. The client's airway could be occluded by the pressure of the examiner's arm. The nurse should count the pulse for a full minute, because the pulse rate is abnormal. The pulse beats should be counted for 30 seconds only if the pulse rate is normal. The nurse should use two fingertips to palpate the carotid pulse. The nurse should never check the carotid pulse on both sides of the neck at the same time; doing so could cut off circulation to the brain, possibly causing cardiac arrest.