Author Question: What steps should the nurse take to conduct an assessment of a possible pulse deficit? a. A nurse ... (Read 52 times)

olgavictoria · **on:** Jun 25, 2018

What steps should the nurse take to conduct an assessment of a possible pulse deficit?

a. A nurse measures the pulse after the patient exercises.
b. Two nurses check the same pulse on opposite sides of the body.
c. Two nurses assess the apical and radial pulses and determine the difference.
d. The current pulse is compared with previous pulse measurements for differences.

Question 2

The general survey begins with a review of the patient's primary health problems and an evaluation of the patient's vital signs, height and weight, general behavior, and appearance.

It also provides information about the patient's illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel?
a. Reporting subjective signs and symptoms
b. Measuring the patient's height and weight
c. Monitoring I&O
d. Obtaining initial vital signs

jamesnevil303 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

C
Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output.

Answer to Question 2

D
Because the initial set of vital signs are part of the general health assessment they must be taken by the nurse. After that, the NAP may take vital signs for a stable patient. The nurse directs NAP to report a patient's subjective signs and symptoms to the nurse, to measure the patient's height and weight, and to monitor oral intake and urinary output.