The nurse has assessed four adult clients. Which client is the priority for the nurse to assess more thoroughly?

Question

Quizplus · Accepted Answer

A pulse of 1+ is thready. This plus the client's tachycardia makes this client the nurse's priority due to having two signs of decreased perfusion. The client with the 4+ (bounding) pulse and slight tachycardia may have fluid overload, putting some strain on the heart and would be assessed next. The client whose pulse is not felt by the nurse has normal appearing distal circulation. If the client also has normal movement and sensation, the nurse would delegate obtaining a Doppler pulse to unlicensed assistive personnel if allowed by facility policy or to another nurse. The client with the 2+ pulse has findings that are within normal limits.

The Nurse Has Assessed Four Adult Clients