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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A reason:

Using cold therapy for a client with peripheral vascular disease is not recommended as it can cause vasoconstriction, further impairing blood flow to already compromised extremities.

B reason:

Using cold therapy for a client with a new ankle sprain is appropriate. Cold therapy helps to reduce swelling, inflammation, and pain associated with acute injuries like sprains.

C reason:

Cold therapy for a client with a spinal cord injury is not typically indicated and may not be beneficial or could potentially cause harm, depending on the extent and location of the injury.

D reason:

Using cold therapy for a client who is unconscious requires careful consideration and is not typically indicated without a specific need. The primary concern with unconscious clients is maintaining overall care and monitoring vital signs.

A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased systolic blood pressure D. Decreased bladder capacity E. Dehydration of intervertebral discs

Correct Answer is ["A","B","D","E"]

Explanation

A reason:

More difficulty seeing due to a greater sensitivity to glare is a common change with aging. The lens of the eye becomes less flexible and more prone to glare.

B reason:

A decreased cough reflex is typical in older adults, making them more susceptible to respiratory infections and complications.

C reason:

Decreased systolic blood pressure is not a common change with aging. Instead, systolic blood pressure often increases due to decreased elasticity of blood vessels.

D reason:

Decreased bladder capacity is a normal part of aging, leading to increased frequency of urination and sometimes incontinence.

E reason:

Dehydration of intervertebral discs occurs with aging, leading to reduced height and potential for back pain and decreased mobility.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","D","E"]

Explanation

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