To assess a patient's apical pulse, the nurse would locate the apical pulse site and

Question

a. gently palpate with the first three fingers for the pulsations.
b. press firmly with all five fingers, because the pulsations are difficult to locate at this site.
c. place the diaphragm of the stethoscope over the pulse site and listen for the heartbeat.
d. palpate the radial pulse while listening to the apical rate with the stethoscope.

Answer 1

C
Measuring the apical pulse is indicated for patients with irregular pulses or known cardiac or pulmonary disease. The assessment of apical pulse can be accomplished through palpation, but it is most commonly accomplished through auscultation. To assess the apical pulse, you place the diaphragm of the stethoscope on the apical pulse site, listen for the heartbeat, and count the pulse rate for 30 seconds if regular, 60 seconds if irregular. To palpate the radial pulse, you place the pad of your first, second, and third fingers at the flexor aspect of the wrist laterally along the radius bone. Option "b" is incorrect because five fingers are never used to locate any pulse site. Palpating the radial pulse while listening to the apical rate with your stethoscope is the procedure for identifying the pulse deficit.