Assessing Apical Pulse

3. 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.

1. 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.

4. 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.

5. 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.

2. 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.