A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?
Radial
Carotid
Apical
Popliteal
The Correct Answer is B
Rationale:
A. The radial pulse is not as reliable as the carotid pulse in assessing circulation during CPR.
B. The carotid pulse is the most reliable site to assess circulation in an adult during CPR because it is closest to the heart and will reflect the true status of central circulation.
C. The apical pulse is not typically assessed during CPR due to its location and difficulty in palpation.
D. The popliteal pulse is not a recommended site for assessing circulation during CPR.
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Correct Answer is C
Explanation
Rationale:
A. Passive range of motion may be performed, but it is not the priority in this situation.
B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.
C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.
D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.
Correct Answer is D
Explanation
Rationale:
A. This response may make the spouse feel pressured by implying that religion should not be a concern, which may not be respectful of the spouse's beliefs.
B. This statement is coercive, focusing on the shortage of organs rather than on the spouse's feelings and the wishes of the deceased.
C. Suggesting that donating organs will make the spouse feel better can be seen as manipulative and may not truly address the spouse's confusion or emotions.
D. Asking what the spouse thinks the deceased would have wanted is appropriate, as it centers on the values and wishes of the deceased, which can guide the spouse in making an informed decision.