Fundamentals: Ch.2 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

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

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

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

Client with atrial fibrillation

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

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

Measure the apical and radial pulse separately.

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.

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

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

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

Both rates are assessed simultaneously.

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