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:
A young adult in skeletal balanced suspension traction is at risk for skin breakdown due to immobility, but they are typically more resilient compared to older adults. Age and overall health are important factors in skin integrity.
B reason:
An older adult with a hip fracture and in Buck's traction is at greatest risk for skin breakdown. Older adults have thinner, more fragile skin, and are more prone to complications from immobility. Buck's traction also limits mobility, increasing the risk of pressure ulcers.
C reason:
An adolescent in a halo brace has a risk for skin breakdown, particularly around the pin sites and under the brace, but adolescents generally have better skin resilience and healing capacity compared to older adults.
D reason:
A middle adult with a fractured radius and an arm cast is at minimal risk for skin breakdown compared to the other scenarios. This situation typically allows for more mobility and less pressure on vulnerable skin areas.
Correct Answer is C
Explanation
A reason: Blood pressure. Blood pressure is an objective measurement that can be quantitatively assessed using a sphygmomanometer. It is not considered subjective data because it does not rely on the client's perception or feelings.
B reason: Cyanosis. Cyanosis, or the bluish discoloration of the skin, is an observable physical sign that can be assessed by the healthcare provider. It is considered objective data, not subjective.
C reason: Nausea. Nausea is a subjective symptom reported by the client. It is based on the client's personal experience and cannot be directly observed or measured by the healthcare provider, making it subjective data.
D reason: Petechiae. Petechiae are small, red or purple spots on the skin caused by minor bleeding. These are observable and measurable physical signs, thus considered objective data.
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