pulse measurement

  • CNA
  • Basic Nursing Skills
  • Multiple choice
  • Difficulty 3 of 5

Question

During a morning round, a nursing assistant feels an uneven rhythm at a resident’s wrist. What should the assistant do with this finding?

  1. Document it and tell the nurse.✓ Correct

    The nurse needs to know about the irregular rhythm.

  2. Chart it only if it becomes regular.✗ Incorrect

    An irregular rhythm itself warrants documentation and reporting.

  3. Wait until the next routine shift report.✗ Incorrect

    The finding should be reported rather than held for routine handoff.

  4. Choose a diagnosis and enter it in the chart.✗ Incorrect

    The assistant reports the observation; the nurse follows up.

Answer

A. Document it and tell the nurse.

Rationale

An uneven pulse rhythm needs communication to the nurse as well as documentation. Counting for a full minute is particularly useful when the rhythm varies.

RememberRecord and report an irregular pulse.

Sources

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