NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s 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’s pulse as 2+ based on the description of a normal pulse.
Therefore, the correct notation for the force of the client’s 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.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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