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 C

Explanation

A reason:

Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that could exacerbate hypernatremia by adding more sodium to the client's system.

B reason:

Lactated Ringer's contains electrolytes, including sodium, which may not be appropriate for a client with hypernatremia who needs to avoid additional sodium.

C reason:

0.45% sodium chloride (half-normal saline) is correct. It is a hypotonic solution that helps to lower sodium levels by diluting the blood and promoting cellular hydration.

D reason:

Dextrose 10% in water is a hypertonic solution and would not be appropriate for treating hypernatremia. It does not address the need to reduce sodium levels and could cause fluid shifts that are not beneficial in this context.

A. I will bear the weight of my body on my hands B. I have a set of my brother's crutches in my basement I can also use C. I will keep spare crutch tips handy D. I will inspect my crutches every day for signs of wear

Correct Answer is B

Explanation

A reason:

Bearing the weight of the body on the hands is correct and indicates proper use of crutches. The weight should be on the hands, not the armpits, to prevent nerve damage.

B reason:

Using a set of crutches that belonged to someone else is not recommended. Crutches should be properly fitted to the individual to ensure safe and effective use. This statement indicates that the client may not understand the importance of having correctly fitted crutches.

C reason:

Keeping spare crutch tips handy is good practice and shows preparedness for maintaining the crutches in good condition.

D reason:

Inspecting crutches daily for signs of wear is also good practice and helps ensure they remain safe and functional for use.

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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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