An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?

Question

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit.  Which assessment technique by the new nurse requires intervention by the RN?

Quizplus · Accepted Answer

The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously. (Option A) Erb's point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs. (Option C) Jugular venous distension should be assessed with the client in semi-Fowler's position (ie, head of the bed elevated at a 30- to 45-degree angle). (Option D) To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart. Educational objective: The nurse should not palpate the carotid arteries simultaneously due to possible vagal stimulation resulting in bradycardia or syncope. Each carotid artery should be palpated separately.

An Experienced Registered Nurse (RN) Is Mentoring a New Nurse