Quiz2 Assessing the Apical Pulse by Auscultation

A client's apical-radial pulse reveals an apical pulse of 72 beats per minute and a radial pulse of 60 beats per minute. How does the nurse document the pulse deficit?

12 - The pulse deficit refers to the difference between the apical and radial pulse rates, which in this case would be 12.

When obtaining a pulse rate for a client with an irregular heart rhythm, how long does the nurse count?

1 minute - When a client has an irregular rhythm, the pulse rate is counted for one full minute to get an accurate measure of beats per minute. Five minutes is not necessary. Any amount of time less than 1 minute is inaccurate for the client without a regular rhythm.

Prior to administering a heart medication, the nurse takes an apical pulse. For how long should the nurse count the pulse?

60 seconds and multiply by 1 - Counting for a full minute increases the accuracy of the assessment. Many times, a client can have cardiovascular problems, causing irregular heartbeats. Certain medications have parameters for the range needed to administer the medication. The apical pulse rate for 1 full minute provides the most accurate data, data which could be missed if the pulse is counted for a shorter period of time.

The clinic nurse is caring for multiple clients. Which client heart rate(s) will the nurse assess apically? Select all that apply.

A 45-year-old client who takes digoxin daily, A 79-year-old client whose radial pulse is 120 beats/minute - The nurse would assess a client's heart rate by using the apical pulse when giving medications that alter heart rate and rhythm, such as digoxin. In addition, if a peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would assess the client's apical rate. A heart rate of 120 beats/minute in an adult is rapid. In adults, the apical rate is counted for 1 full minute by listening with a stethoscope over the apex of the heart. A radial pulse can be used in pediatric clients over 2 years of age, clients with normal heart rates, clients with a fever, and pregnant clients. If the nurse were to note any abnormalities while assessing the radial pulse, the nurse would assess the client's apical pulse for 1 full minute.

To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest?

Between the fifth and sixth ribs - When assessing the apical pulse, the nurse would place the stethoscope between the fifth and sixth ribs at the left midclavicular line of the client's chest. The midclavicular line is the point of maximum impulse. This is the location of the apex of the heart. It is where the strongest heart sounds are located. The nipple level, the axilla area and below the clavicle are not anatomical locations for the apex of the heart.

A group of students are reviewing information about taking an apical-radial pulse. Which information is accurate?

Both rates are assessed simultaneously. - An apical-radial pulse involves assessing the apical and radial pulse rates simultaneously, with both counts starting at the same specified time. Two nurses are needed for this assessment: one to count the radial pulse rate; the other to count the apical pulse rate. The rates are counted over a period of 1 minute. An apical radial pulse is typically obtained for clients with an irregular radial pulse.

Which client would require the nurse to obtain an apical-radial pulse?

Client with atrial fibrillation - Atrial fibrillation is a condition in which the radial pulse and the apical pulse exhibit different measurements. This occurs due to frequent and ineffective apical beats that do not reach the periphery. Although atrial fibrillation can occur with other conditions, atrial fibrillation is not expected with aortic stenosis or heart failure. Sinus tachycardia indicates the client has a faster than normal rhythm, but it is a regular rhythm that does not create a pulse deficit.

What is the best way for the nurse to promote comfort for the client when assessing an apical pulse?

Holding the stethoscope's diaphragm against the palm of the hand for a few seconds - Holding the diaphragm of the stethoscope against the palm of the hand for a few seconds warms the diaphragm and prevents chilling, thereby promoting client comfort. Wiping the bell and diaphragm of the stethoscope with an alcohol swab between uses reduces the risk of microorganism transmission. Assisting the client to a sitting or reclining position facilitates identifying the appropriate site for placement of the stethoscope. Exposing the chest area at the apical site allows for assessment and maintains the client's privacy and dignity.

Which action does the nurse include when measuring the client's pulse deficit?

Measure the apical and radial pulse separately. - The apical and radial pulses can be auscultated and palpated at the same time, but they must be measured separately to obtain the actual pulse deficit. The pulse oximetry monitor may deliver an inaccurate reading. The carotid pulse is not used in the measurement of pulse deficit.

A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment?

Over the space between the fifth and sixth ribs on the left midclavicular line - The apical pulse is measured over the apex of the heart, which is located approximately in the area of the space between the fifth and sixth ribs on the left midclavicular line.

When measuring an apical pulse, what equipment would the nurse prepare to have available?

Stethoscope - A nurse uses a stethoscope to assess an apical pulse. A sphygmomanometer is used to assess blood pressure. Tissues would most likely be necessary when assessing a rectal temperature. A doppler would only be used in auscultating peripheral pulses.

The unlicensed assistive personnel (UAP) reports to the nurse that the client's pulse is difficult to feel and is skipping beats. What action should the nurse take?

Take an apical pulse. - When the radial pulse is difficult to palpate or is irregular, the most accurate way to assess the client's pulse is by assessing the apical pulse. The stethoscope allows for amplification of the sounds so that pulse may be counted. When clients have weak or irregular pulses, are on certain medications, or are debilitated, the apical pulse provides the most accurate information.