The nurse is caring for a client who is experiencing acute hemorrhagic shock. The client's blood pressure is 60/28. How will the nurse assess this client's pulse?
1. Measure the radial pulse for 1 minute.
2. Measure the brachial pulse for 1 minute.
3. Measure the radial pulse for 30 seconds and multiply by 2.
4. Measure the client's apical pulse for 1 minute.
Correct Answer: 4
In all likelihood, a client whose blood pressure is this low who is in shock will not have a radial or brachial pulse because perfusion will be significantly diminished. The most accurate pulse assessment will be obtained centrally, and the nurse can either auscultate apical pulsation or palpate carotid pulsation. Care should be taken not to ever palpate both carotid arteries at the same time.
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