PTS: 1 DIF: Cognitive Level: Application REF: 384 OBJ: 5 (theory) TOP: Auscultating for Murmur KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance13. When using a 0 to 4+ scale to grade pulse quality, how should the nurse record a normal volume pulse? a. 1+b. 2+c. 3+d. 4+ANS: C A 0 to 4+ scale for grading pulse quality is as follows: 0—Absent, +1—Weak, thready, +2—Light volume, +3—Normal volume, and +4—Full, bounding. The nurse should be aware of the type of scale used in different facilities.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 385, Box 17-2 OBJ: 5 (theory) TOP: Recording Pulse Quality KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. The nurse is caring for a patient with a blood pressure of 140/90, an apical pulse of 82, and a radial pulse of 76. Which value indicates that the nurse accurately calculated the patient’s pulse pressure?