When assessing the apical-radial pulse using the two-nurse ...

[bucstennis@aim.com]

When assessing the apical-radial pulse using the two-nurse method, the nurses include which of the following? Select all that apply. Standard Text: Select all that apply.
 
  1. Place the client supine with the HOB elevated 30 degrees.
  2. Locate the PMI and radial pulses.
  3. Locate the femoral pulses.
  4. Each nurse counts for 30 full seconds.
  5. Each nurse utilizes his own watch.

Question 2

The nurse working in a long-term care facility safely delegates which of the following to the unlicensed assistive personnel (UAP)?
 
  1. Bathing a client who is showing signs of imminent death
  2. Obtaining vital signs on a client who developed shortness of breath
  3. Providing fresh ice and water to everyone on the unit
  4. Transferring an elderly man from the chair to the bed independently

[cassie_ragen]

Answer to Question 1

1,2
Rationale: The client is placed in a supine position with the head of the bed elevated or the bed in the position used for the last assessment, if known. Each nurse locates the site to be assessed, either radial or apical pulse. The femoral pulse is not used. One watch is used, and it is placed so that both nurses can see it, or one nurse indicates when to start and stop. The pulse is counted for a full 60 seconds.

Answer to Question 2

3
Rationale: The UAP can safely fill water pitchers for the clients on the unit. The client who is showing signs of imminent death should be bathed, if absolutely needed, by the nurse. An unstable client should have vital signs assessed by the nurse. Transferring a client from chair to bed is rarely done alone, and usually requires others to make the move safely.

[bucstennis@aim.com]

Excellent

[cam1229]

Thanks for the timely response, appreciate it