Vital Signs
Assessing the Apical-Radial Pulse
Review Questions
1. The nurse assesses the patient’s apical-radial pulse to help determine possible cardiac
dysrhythmias that most importantly may result in:
1. A pulse deficit.
2. Activity intolerance.
3. Decreased cardiac output.
4. Impaired tissue perfusion.
2. Which of the following statements made by the nurse will be most effective in instructing
ancillary staff regarding the appropriate technique for assisting in monitoring the adult
patient’s radial-apical pulse?
1. “Please review the patient’s previous pulse measurements.”
2. “You will be assessing the radial pulse for a full 60 seconds.”
3. “Make sure the patient is comfortable before measuring the pulse.”
4. “I’ll be listening for the apical pulse at the fifth intercostal space over midclavicle.”
3. Which of the following actions would have priority when determining that the apical-radial
pulse confirms the presence of a pulse deficit?
1. Reassess the apical-radial pulse in 5 minutes.
2. Assess the patient for signs of decreased cardiac output.
3. Notify the primary health care provider of the pulse deficit.
4. Provide interventions directed toward managing patient symptoms.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.
Review Questions
2
4. Which of the following statements made by ancillary staff assigned to assist with the
measuring of an apical-radial pulse of an elderly patient shows the best understanding of the
importance of adhering to the established procedural guidelines?
1. “Her left radial pulse was 114 beats per minute, weak, and thready.”
2. “I recorded the patient’s apical-radial pulse on the flow sheet as you asked.”
3. “I counted the left radial pulse for a full minute starting when you told me to.”
4. “Her respirations were 22 per minute with 2 liters of oxygen per nasal cannula.”
5. Which of the following signs and symptoms would best indicate early identification of
decreased cardiac output?
1. Easily fatigued
2. Substernal pain
3. Nailbed cyanosis
4. Shortness of breath
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.