The nurse is going to assess the apical-radial pulse of a client with

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision?

1. A forceful radial pulse is much too difficult to count correctly.
2. Both arteriole and venous sounds were heard simultaneously.
3. The pulse was bounding and easily obliterated.
4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

ANSWER

Correct Answer: 4
Rationale 1: A forceful radial pulse would be ideal for assessing a client’s peripheral pulse.
Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation.
Rationale 3: A bounding pulse is not easily obliterated.
Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the client’s pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites.