Clinical Skills Pulse

Which of the following is an early manifestation of decreased cardiac output? A. Fatigue B. Substernal pain C. Nail bed cyanosis D. Shortness of breath

A. Fatigue Rationale: Fatigue is an early indicator of cardiac insufficiency. Substernal pain can be caused by a variety of disease processes (such as respiratory diseases or esophageal reflux) and does not necessarily indicate decreased cardiac output. Chest pain may occur as a later symptom of decreased cardiac output. Nail bed cyanosis can occur with respiratory or hematology diseases and does not necessarily indicate decreased cardiac output. Shortness of breath can be caused by a variety of disease processes (such as respiratory and hematology diseases) and does not necessarily indicate decreased cardiac output.

Which action would best assess the effect of exercise on a patient's radial pulse measurement? A. Measuring the patient's radial pulse before and after exercise. B. Assessing the patient's radial pulse 30 minutes after exercise. C. Comparing the patient's radial and apical pulses after exercise. D. Comparing the patient's pre-exercise radial and post-exercise apical pulses.

A. Measuring the patient's radial pulse before and after exercise. Rationale: Measuring the patient's radial pulse before and after exercise best assesses the effect of the exercise on the radial pulse because it compares the same pulse site before and after exercise. Thirty minutes after exercise is too long to wait to obtain useful information about the effect of exercise on the patient's radial pulse. Assessing the patient's apical pulse will not determine the effect of exercise on the radial pulse. Assessing the patient's apical pulse, whether pre-exercise or post-exercise assessment, will not determine the effect of exercise on the radial pulse.

Which action would take priority if a patient's apical pulse has an irregular rhythm? A. Reassess the pulse for 1 full minute. B. Assess the patient's peripheral pulses. C. Wait 5 minutes, and then reassess the apical pulse. D. Review documentation regarding an irregular rhythm.

A. Reassess the pulse for 1 full minute. Rationale: A second measurement confirms the initial findings of an irregular heart rate. Irregular rate is more accurately assessed when measured over a longer interval. Peripheral pulse assessment is not a priority. Apical pulse is the most accurate pulse site. An irregular apical pulse already indicates an alteration in cardiac output. Waiting 5 minutes to reassess the apical pulse is not a priority action and could be dangerous in some unstable cardiac conditions. Reviewing documentation regarding an irregular rhythm is not the priority action, because establishing a history of irregular heartbeat is not essential.

Inadequate oxygenation to the body will cause the radial pulse to become: A. Tachycardic B. Bradycardic C. Irregular D. Bounding

A. Tachycardic Rationale: The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is more than 100 beats/minute. The heart rate will increase, not decrease. Bradycardia is less than 60 beats/minute. Heart rhythm (regular or irregular) is determined by the electrical conduction through the heart, not oxygenation. A bounding pulse indicates increased blood volume ejected against the arterial wall.

You have the following information: Oral temperature-36.8°C.Radial Pulse-112 weak, threadyApical pulse-117 regularRespirations-24 regularBlood Pressure-104/56 right arm-102/50 left arm What is the pulse deficit? A. 2 B. 5 C. 6 D. 48

B. 5 Pulse deficit is the difference between the apical and radial pulse rates (117 - 112 = 5). The answer 2 is the difference in systolic pressure between the right and left arm. The answer 6 is the difference in diastolic pressure between the right and left arm. The answer 48 is the difference between the systolic and diastolic pressure in the right arm, known as the pulse pressure.

What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? A. Reassess the pulse for 1 full minute. B. Assess the patient for a pulse deficit. C. Wait 5 minutes, and then reassess the pulse. D. Review documentation regarding an irregular rhythm.

B. Assess the patient for a pulse deficit. Rationale: Assessing the patient for a pulse deficit is useful in identifying an alteration in cardiac output. Although reassessing the pulse is appropriate, this is not the priority action because the presence of an irregular rhythm has already been established. Waiting 5 minutes to reassess the radial pulse is not appropriate and could be dangerous for the patient in some unstable cardiac conditions. Reviewing documentation is not the priority action because establishing a history of an irregular heartbeat is not essential.

Which action should the nurse perform after identifying a pulse deficit? A. Reassess the apical-radial pulse in 5 minutes. B. Assess the patient for signs of decreased cardiac output. C. Notify the primary health care provider of the pulse deficit. D. Initiate interventions directed toward managing the patient's symptoms.

B. Assess the patient for signs of decreased cardiac output. Rationale: The patient must be assessed for cardiac manifestations of the pulse deficit. Reassessing the apical-radial pulse is not necessary, since the pulse deficit has already been identified. Notifying the primary health care provider of the pulse deficit is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit. Symptom management is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit before initiating interventions.

During the admissions process, the nurse initially assesses the patient's radial pulse primarily for what purpose? A. Assessment of peripheral blood perfusion B. Establishment of a baseline as part of the patient's vital signs C. Assessment of the patient's cardiovascular disease risk D. Determination of oxygen saturation

B. Establishment of a baseline as part of the patient's vital signs Rationale: It is essential to establish a point of reference against which future radial pulse rate measurements can be compared. Assessment of peripheral blood perfusion is not the primary reason for assessing the radial pulse during the admission process. Assessing radial pulse will not necessarily provide information about the patient's risk for cardiovascular disease. Other factors (such as age, smoking, dietary patterns, and exercise habits) contribute to the risk for cardiovascular disease. Pulse oximetry is the measurement of arterial blood oxygen saturation, not a radial pulse.

What is the primary purpose of initially assessing an apical pulse? A. Assessment of the patient's cardiac function B. Establishment of a baseline as part of the patient's vital signs C. Assessment of the patient's risk for cardiovascular disease D. Determination of oxygen saturation

B. Establishment of a baseline as part of the patient's vital signs Rationale: The primary purpose for initially assessing an apical pulse is establishing a baseline for the patient against which future assessments of apical pulse rate can be compared. The apical pulse rate provides some information about the patient's cardiac function; however, obtaining such information is not the primary goal of conducting this assessment at this time. Measuring the apical pulse rate does not adequately assess the patient's risk for cardiovascular disease. Other factors (such as age, smoking, dietary patterns, and exercise habits) contribute to the risk for cardiovascular disease. Pulse oximetry is the measurement of arterial blood oxygen saturation, not an apical pulse.

What is the major health problem resulting from a pulse deficit? A. Bradycardia B. Activity intolerance C. Decreased cardiac output D. Impaired tissue perfusion

C. Decreased cardiac output Rationale: Decreased cardiac output is the major problem indicated by a pulse deficit. Decreased cardiac output may lead to other problems, such as activity intolerance. Bradycardia is a pulse rate less than 60 beats/minute. This can occur without a pulse deficit. Activity intolerance may or may not occur with a pulse deficit. Impaired tissue perfusion may or may not occur with a pulse deficit. Decreased cardiac output may lead to impaired tissue perfusion. A cardiac dysrhythmia may lead to impaired tissue perfusion, but the impaired perfusion itself is not the most important possible result of the dysrhythmia.

Which statement demonstrates an understanding of the importance of communicating changes in the patient's apical pulse rate? A. "The patient's apical pulse is recorded as you asked." B. "The apical pulse is more difficult to hear when the patient is sitting up." C. "The apical pulse is usually slower in the morning than it is in the afternoon." D. "The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom."

D. "The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom." Rationale: This statement identifies a significant change in the patient's apical pulse rate and the reason for the deviation in the rate. Recording the patient's apical pulse pertains to documentation, not to changes in apical pulse rate. While sitting up may make it more difficult to hear the apical pulse this may be true for an individual patient, it does not pertain to changes in the patient's apical pulse rate. The general statement that the apical pulse is usually slower in the morning than it is in the afternoon may or may not be accurate; it does not pertain to a significant change in the patient's apical pulse rate.

What should the nurse do when a pulse deficit is suspected? A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute. B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds. C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute. D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.

D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse. Rationale: The nurse counts the apical pulse while another health care provider counts the radial pulse. To identify pulse deficit, the apical and radial pulses must be measured at the same time. A more accurate measurement is obtained when apical pulse rate is assessed over a longer interval (count 1 full minute).

The nurse can best determine the effect of crying on a patient's apical pulse by doing what? A. Measuring the patient's apical pulse before and after crying B. Assessing the patient's apical pulse 30 minutes after crying C. Measuring the patient's pulse deficit after crying D. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate

D. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate Rationale: The comparison of apical pulse rates at these times is the best means of evaluating the effect of crying on the patient's apical pulse rate. These values would be available data to compare. It is unlikely that the nurse will have the opportunity to measure the patient's apical pulse before and after crying. The time interval of 30 minutes is too long to effectively assess the effect of the crying on the apical pulse. Pulse deficit indicates alterations in cardiac output, not the effect of the emotional reaction.

What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient's radial pulse? A. Place the patient in the lateral (side-lying) position before measuring the pulse. B. Apply gloves with each patient before measuring the pulse. C. Document whether the patient's pulse is bounding or has diminished. D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers.

D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers. Rationale: The thumb side of the wrist easily accesses the radial artery for the radial pulse. The ulnar artery is on the little finger side of wrist. The nurse's thumb has pulsation that will interfere with accuracy; therefore the fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The patient may assume a sitting or supine position before measuring the radial pulse. Gloves are not usually required to measure the radial pulse. The radial pulse site harbors normal skin flora, not pathogenic microorganisms, in the general population. Documenting whether the patient's pulse is bounding or has diminished pertains to documentation of the procedure, not to the procedure itself.

What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient's apical pulse? A. Document the patient's pulse rate and rhythm. B. Place the patient in the right lateral position before measuring the apical pulse. C. Review the patient's previous apical pulse measurements. D. Place your stethoscope at the fifth intercostal space over the left midclavicular line.

D. Place your stethoscope at the fifth intercostal space over the left midclavicular line. Rationale: These anatomical landmarks allow correct placement of the stethoscope over the apex of the heart. Documenting the patient's pulse rate and rhythm pertains to documentation, not technique. The patient may assume a sitting or supine position before measuring the apical pulse. The heart is located to the left of the sternum. If unable to locate the point of maximal impulse (PMI), reposition the patient on the left side to hear the sounds more clearly. Reviewing the patient's previous apical pulse measurements does not pertain specifically to the technique or procedure itself.