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 A
Explanation
A reason:
Storing oxygen tanks upright is correct. This prevents them from tipping over and ensures the safety of the oxygen supply. Proper storage minimizes the risk of accidents and maintains the integrity of the oxygen tanks.
B reason:
Keeping oxygen tanks 4 feet away from an electric stove is not sufficient. Oxygen tanks should be kept away from all heat sources and open flames, as oxygen can support combustion and increase the risk of fire.
C reason:
Choosing a wool blanket is incorrect. Wool can generate static electricity, which poses a fire hazard when using oxygen. Cotton or other non-static generating materials are safer options for blankets when using home oxygen therapy.
D reason:
Using petroleum-based ointments to moisturize lips is dangerous. Petroleum products are flammable and should not be used with oxygen therapy. Water-based or non-flammable moisturizers should be used instead.
Correct Answer is C
Explanation
A reason:
BUN (blood urea nitrogen) is primarily used to assess kidney function and hydration status. It is not a direct indicator of infection.
B reason:
RBC (red blood cell) count measures the number of red blood cells and is used to assess anemia and other blood disorders. It does not indicate infection.
C reason:
WBC (white blood cell) count is correct. An elevated WBC count is a common indicator of infection, as white blood cells are part of the body's immune response to fight off pathogens.
D reason:
Potassium levels are related to electrolyte balance and are not directly indicative of infection.
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