Asked by Maria Martinez on Mar 10, 2024
Verified
The nurse notes that the patient's radial pulse is irregular.What is the most appropriate first action of the nurse?
A) Document the finding in the patient's medical record.
B) Count the patient's apical pulse for 1 full minute.
C) Assess the brachial pulse for a pulse deficit.
D) Notify the health care provider immediately.
Radial Pulse
The pulse felt at the wrist where the radial artery runs, used to measure heart rate and rhythm.
Apical Pulse
The heart rate as measured at the apex of the heart, typically through auscultation with a stethoscope, reflective of the actual heartbeat.
Pulse Deficit
The difference between the heart rate measured at the apex of the heart and the rate measured at the wrist or other peripheral site, indicating a discrepancy in the heart's efficiency.
- Exhibit understanding of the physiological consequences associated with atypical vital sign measurements.
Verified Answer
KH
Kendra HughesMar 10, 2024
Final Answer :
B
Explanation :
Irregular peripheral pulses should be compared to the patient's apical pulse to determine if a pulse deficit is present.To assess a pulse deficit,ask another nurse to assess the radial pulse rate while you assess the apical rate.The finding should not be documented in the chart until the apical pulse is checked.The health care provider does not need to be notified immediately.
Learning Objectives
- Exhibit understanding of the physiological consequences associated with atypical vital sign measurements.