Author Question: When evaluating the radial pulse measurement technique of the nursing assistant, the nurse ... (Read 47 times)

vicotolentino · **on:** Jul 24, 2018

When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant:

A. Has the client's arm elevated
B. Positions the client supine or sitting
C. Applies significant pressure to the pulse site
D. Counts the pulse for 15 seconds and multiplies by four

Question 2

The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?

a. Hypotonic or isotonic solutions
b. Hypertonic or isotonic solutions
c. Hypertonic solutions only
d. Whole blood

aidanmbrowne · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

B
B. Assist client with assuming a supine or sitting position.
A. If supine, place client's forearm straight alongside or across lower chest or upper abdomen with wrist extended straight. If sitting, bend client's elbow 90 degrees and support lower arm on chair or on nurse's arm. Slightly extend or flex wrist with palm down until strongest pulse is noted.
C. Lightly compress against radius, obliterate pulse initially, and then relax pressure so pulse becomes easily palpable. Pulse is more accurately assessed with moderate pressure. Too much pressure occludes pulse and impairs blood flow.
D. If pulse is regular, count rate for 30 seconds and multiply total by 2. If pulse is irregular, count rate for 60 seconds. Assess frequency and pattern of irregularity.

Answer to Question 2

A
Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss.