A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess the pedal pulses with a Doppler device
Assess the pedal pulses for a full minute
Assess the apical pulse with a Doppler device
Assess the apical pulse for a full minute
The Correct Answer is D
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.
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Correct Answer is D
Explanation
A. Applying the pulse oximeter to a finger may not be ideal due to edema, which can affect the accuracy of the reading.
B. Using a skin fold is not a typical location for pulse oximetry and may not provide accurate readings.
C. Applying the probe to a toe may be less effective if the toenails are thickened, potentially affecting blood flow to that area and the accuracy of the reading.
D. The earlobe is a suitable alternative for measuring oxygen saturation, particularly in cases where peripheral sites (like fingers or toes) are compromised.
Correct Answer is C
Explanation
A. Milk, eggs, and cheese are primarily sources of protein and fats, with minimal carbohydrates.
B. Chicken is a protein source, while green beans and apples provide some carbohydrates, but not at the same level as the correct answer.
C. Rice, potatoes, and oranges are all high in carbohydrates, making this the group with the highest carbohydrate content. Rice and potatoes are starchy foods, while oranges provide simple carbohydrates.
D. Butter, oils, and avocados are high in fats and contain negligible carbohydrates.