Page 300 - Saunders Comprehensive Review For NCLEX-RN

(ankle bone).
10. The dorsalis pedis pulse is located on the top of the
foot, in line with the groove between the extensor
tendons of the great and first toes.

The apical pulse is counted for 1 full minute and is assessed in

clients with an irregular radial pulse or a heart condition, before the
administration of cardiac medications such as digoxin and beta
blockers, and in children younger than 2 years.
E. Pulse deficit
1. In this condition, the peripheral pulse rate (radial
pulse) is less than the ventricular contraction rate
(apical pulse).
2. A pulse deficit indicates a lack of peripheral perfusion;
it can be an indication of cardiac dysrhythmias.
3. One-examiner technique: Auscultate and count the
apical pulse first and then immediately count the
radial pulse.
4. Two-examiner technique: One person counts the
apical pulse and the other counts the radial pulse
simultaneously.
5. A pulse deficit indicates that cardiac contractions are
ineffective, failing to send pulse waves to the
periphery.
6. If a difference in pulse rate is noted, the PHCP is
notified.
IV. Respirations
A. Description
1. Respiration is a mechanism the body uses to exchange
gases between the atmosphere and the blood and
between the blood and the cells.
2. Respiratory rates vary with age.
3. The normal adult respiratory rate is 12 to 20 breaths
per minute.

B. Nursing considerations

1. Many of the factors that affect the pulse rate also affect
the respiratory rate.
2. An increased level of carbon dioxide or a lower level
of oxygen in the blood results in an increase in
respiratory rate.
3. Head injury or increased intracranial pressure will
depress the respiratory center in the brain, resulting
in shallow respirations or slowed breathing.
4. Medications such as opioid analgesics depress
respirations.
5. Additional factors that can affect the respiratory rate

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