Author Question: The nurse is assessing a 15-month-old toddler client. Which site is the most appropriate for the ... (Read 70 times)

appyboo · **on:** Jun 25, 2018

The nurse is assessing a 15-month-old toddler client. Which site is the most appropriate for the nurse to use when assessing the pulse?

1. Radial artery.
2. Brachial artery.
3. Apical site.
4. Carotid artery.

Question 2

During the assessment of an adult client's blood pressure, the nurse notes the following on the sphygmomanometer:

first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. This nurse would document this client's blood pressure as _____________.
Record your answer as a fraction.

chjcharjto14 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3

The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age. In preschool children, the brachial artery is used to assess the pulse. In older children and adults, the radial artery is used to assess the pulse. The carotid pulse is assessed in adult clients as part of the cardiovascular assessment.

Answer to Question 2

Correct Answer: 136/76

The sounds above are the five phases of Korotkoff's sounds. The first sound heard (Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is marked by the period in which the sounds change from tapping to swishing; blood flows turbulently through the artery. Phase 3 is when blood flows through the artery during systole but collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the beginning of silence (Phase 5). This is when the cuff no longer collapses the artery, and blood is free flowing through the artery.