NCLEX-RN

Category - Reduction of Risk

A student nurse is reading the client’s chart, and came upon a physician’s order to take the pulse pressure of the client. The charge nurse should intervene when the student is seen:
  1. Taking the apical pulse and radial pulse simultaneously.
  2. Taking the blood pressure, and then subtracting the diastolic value from the systolic value.
  3. Taking the radial pulse and dorsalis pedis pulse simultaneously.
  4. Taking the blood pressure, and then subtracting it from the previous blood pressure.
Explanation
Answer: B - A pulse pressure is taken by subtracting the systolic pressure from the diastolic pressure. Pulse pressure is an indicator of cardiovascular problems. A wide pulse pressure is seen in clients with reduced vascular compliance, such as in hypertension. On the other hand, a narrow pulse pressure may indicate tachycardia, aortic stenosis, ascites, or pericardial effusion. Option A pertains to pulse deficit.
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