A nurse assesses a client's radial pulse as 52 beats/minute. Which action should the nurse take next?

Obtain the client's apical heart rate

Assess for a pulse deficit

Notify the healthcare provider

Review previous vital sign trends

Answer and Explanation

The Correct Answer is A

A. Obtain the client's apical heart rate: A radial pulse of 52 beats/minute is below the normal adult range (60–100 bpm), indicating bradycardia. Assessing the apical heart rate provides a more accurate measure of cardiac output and identifies potential discrepancies between central and peripheral pulses. This step is the immediate priority before further interventions.

B. Assess for a pulse deficit: Pulse deficit measurement compares apical and radial pulses to identify ineffective contractions, often in atrial fibrillation. This assessment is secondary and requires the apical pulse first.

C. Notify the healthcare provider: While notification may be necessary depending on findings, the nurse must first verify the heart rate and assess the client’s condition before contacting the provider. Immediate confirmation guides appropriate communication.

D. Review previous vital sign trends: Reviewing trends is useful to determine if bradycardia is new or chronic, but it does not replace the immediate need to accurately assess the current cardiac status. Immediate verification takes priority.

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Correct Answer is B

Explanation

A. Sit the client up in High Fowler's: Elevating the head of the bed can improve lung expansion and oxygenation, but it does not immediately address the critically low respiratory rate and oxygen saturation. This action is supportive but not the highest priority.

B. Call the rapid response team: A respiratory rate of 6 breaths per minute and oxygen saturation of 71% indicate severe hypoxemia and impending respiratory failure. Immediate activation of the rapid response team ensures rapid, coordinated intervention to prevent cardiac or neurologic compromise. Life-threatening instability requires prompt action.

C. Monitor respiratory rate and depth: Ongoing assessment is important, but monitoring alone does not intervene in a life-threatening situation. The client’s condition is critical, and delaying active intervention could result in deterioration. Assessment must be accompanied by emergency response.

D. Prepare for possible intubation: Preparation for intubation is appropriate, but initiating the rapid response team first ensures timely support, equipment, and personnel are available. Immediate coordination is required before advanced procedures.

A. Clean frequently touched surfaces with disinfectant wipes B. Wear gloves during all direct contact with clients C. Wash hands before and after contact with each client D. Clean equipment used for client care with disinfectant wipes

Correct Answer is C

Explanation

A. Clean frequently touched surfaces with disinfectant wipes: Environmental cleaning reduces the microbial load on surfaces, lowering the risk of indirect transmission. While important, it is not as effective as interrupting direct transmission at the source.

B. Wear gloves during all direct contact with clients: Gloves protect against exposure to bodily fluids and pathogens, but they are not a substitute for proper hand hygiene. Microorganisms can still be transmitted if hands are not washed before and after glove use.

C. Wash hands before and after contact with each client: Hand hygiene is the single most effective measure to prevent the spread of microorganisms in healthcare settings. It removes transient pathogens acquired from clients, surfaces, or equipment and significantly reduces healthcare-associated infections.

D. Clean equipment used for client care with disinfectant wipes: Disinfecting shared equipment helps prevent indirect transmission, but it is supplementary to hand hygiene. Equipment cleaning alone does not address pathogens transmitted via direct contact.

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A nurse assesses a client's radial pulse as 52 beats/minute. Which action should the nurse take next?

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