A nurse is caring for a client and auscultates an apical heart rate of 100/min. Which of the following actions should the nurse take?
Call the provider
Prepare the client for a chest x-ray
Ask another nurse to verify the heart rate
Document this as an expected finding
The Correct Answer is D
A reason:
Calling the provider is unnecessary for an apical heart rate of 100/min unless there are other concerning symptoms. This heart rate is within the upper range of normal, especially if the client is active or anxious.
B reason:
Preparing the client for a chest x-ray is not warranted solely based on a heart rate of 100/min. Other clinical indications would be needed to justify this diagnostic test.
C reason:
Asking another nurse to verify the heart rate is not required. A heart rate of 100/min is within the normal range and does not typically necessitate double-checking unless there are irregularities or other concerns.
D reason:
Documenting this as an expected finding is correct. An apical heart rate of 100/min is within the normal range, especially in situations of mild exertion or stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A reason:
Asking the client to look down when instilling the solution is incorrect. The client should be asked to look up to expose the lower conjunctival sac, which is the proper site for administering eye drops.
B reason:
Holding the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac is correct. This distance helps to prevent contamination of the dropper and ensures accurate delivery of the medication into the eye.
C reason:
Approaching the client's eye from below is not standard practice. The eye dropper should be held above the eye to allow gravity to assist in the administration of the drops.
D reason:
Instilling the drops into the inner canthus is incorrect. The drops should be placed into the lower conjunctival sac to ensure proper absorption and effectiveness of the medication.
Correct Answer is D
Explanation
A reason:
Making sure the room temperature is cool may not be comfortable for an older adult client, who may be more sensitive to cold. Ensuring a comfortable room temperature is important, but the focus should be on clear communication and patient comfort.
B reason:
Providing music as an environmental distraction can be helpful, but it is not the most critical action to take when preparing a client for an examination. Clear explanations and reassurance take precedence to ensure the client understands and feels comfortable with the process.
C reason:
Informing the client that the provider will examine sensitive areas first is not appropriate. Sensitive areas should generally be examined last to reduce the patient's anxiety and discomfort. It is more important to explain the examination sequence and provide reassurance.
D reason:
Explaining to the client what is about to happen is essential. Clear communication helps to alleviate anxiety, ensure cooperation, and build trust between the client and healthcare provider. It is crucial to provide a step-by-step explanation of the examination process.
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