A patient’s radial pulse feels irregular. Which method should the nurse use to obtain the most reliable rate?
Correct answer: C. Count the apical pulse for a full minute
- A. Count for 15 seconds and multiply by four
- B. Count for 30 seconds and multiply by two
- C. Count the apical pulse for a full minute
- D. Estimate the rate from the monitor display
Explanation
An irregular pulse should be counted at the apical site for a full minute to identify the true rate and rhythm. Shorter counts can miss variations, and a monitor display should not replace direct assessment when the pulse is irregular.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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