Quiz: 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? 132 12 60 72

12

When obtaining a pulse rate for a client with an irregular heart rhythm, how long does the nurse count? 30 seconds 1 minute 5 minutes 15 seconds

1 minute

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? Auscultate with a doppler. Take an apical pulse. Notify the health care provider. Document the findings.

Take an apical pulse.

Prior to administering a heart medication, the nurse takes an apical pulse. For how long should the nurse count the pulse? 30 seconds and multiply by 2 45 seconds and multiply by 2 15 seconds and multiply by 4 60 seconds and multiply by 1

60 seconds and multiply by 1

The clinic nurse is caring for multiple clients. Which client heart rate(s) will the nurse assess apically? Select all that apply. A 22-year-old athletic client whose resting heart rate was 52 beats/minute yesterday A 45-year-old client who takes digoxin daily A 17-year-old client who is at 32 weeks' gestation with her first child An 8-year-old client being seen for immunizations A 38-year-old client whose oral temperate is 102.2°F (39°C) A 79-year-old client whose radial pulse is 120 beats/minute

A 79-year-old client whose radial pulse is 120 beats/minute A 45-year-old client who takes digoxin daily

To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest? Just below the clavicle Between the fifth and sixth ribs Even with the axilla At the nipple level

Between the fifth and sixth ribs

A group of students are reviewing information about taking an apical-radial pulse. Which information is accurate? It requires a total of three nurses to perform the skill. Both rates are assessed simultaneously. Each rate is counted over a period of 30 seconds. It is used routinely for any client with a heart problem.

Both rates are assessed simultaneously.

Which client would require the nurse to obtain an apical-radial pulse? Client with sinus tachycardia Client with aortic stenosis Client with atrial fibrillation Client with heart failure

Client with atrial fibrillation

What is the best way for the nurse to promote comfort for the client when assessing an apical pulse? Wiping the stethoscope's bell and diaphragm with an alcohol swab Exposing the chest area at the apical site Holding the stethoscope's diaphragm against the palm of the hand for a few seconds Assisting the client to a sitting or reclining position

Holding the stethoscope's diaphragm against the palm of the hand for a few seconds

Which action does the nurse include when measuring the client's pulse deficit? Measure the apical and radial pulse separately. Palpate the carotid pulse and compare to the radial pulse. Use the pulse oximetry monitor to measure the radial pulse. Count the apical and radial pulse rate simultaneously.

Measure the apical and radial pulse separately.

A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment? Over the carotid artery in the anterior neck Over the radial artery on the anterior wrist Over the space between the fifth and sixth ribs on the left midclavicular line In the center of the upper back

Over 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 Doppler Tissues Sphygmomanometer

Stethoscope