Difficulty: Medium
Average Score: 89%
Simulated
A nurse palpates a client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós radial pulse, noting the rate, rhythm, and force, and concludes that the client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós pulse is normal. Which notation would the nurse make in the client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós record to document the force of the client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós pulse?
Correct answer
C
Rationale
When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client├âãÆ├é┬ó├â┬ó├óÔé¼┼í├é┬¼├â┬ó├óÔé¼┼¥├é┬ós pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.