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 A

Explanation

A reason:

Removing all metal necklaces is correct because metal objects can interfere with the x-ray imaging. Metal can cause artifacts on the x-ray, making it difficult to interpret the results accurately. Therefore, clients are advised to remove any metal jewelry or accessories before the procedure.

B reason:

Taking several shallow breaths during the procedure is not correct. Clients are usually instructed to take a deep breath and hold it for a few seconds while the x-ray is being taken. This helps to get a clear image of the chest.

C reason:

Not eating or drinking anything the morning of the test is not necessary for a chest x-ray. This instruction is more relevant for certain other tests, such as blood tests or imaging studies requiring contrast. For a chest x-ray, there are no such restrictions.

D reason:

Expecting minor discomfort after the procedure is incorrect. A chest x-ray is a non-invasive and painless procedure. Patients typically do not experience any discomfort afterward.

A. Have the client wear a mask. B. Notify the x-ray department that the client requires airborne precautions. C. Wear a filtration mask and gloves during transport. D. Ask the x-ray technician to come to the client's room to obtain a portable x-ray.

Correct Answer is A

Explanation

A reason:

Having the client wear a mask is correct. This helps to contain respiratory droplets and prevent the spread of tuberculosis during transport.

B reason:

Notifying the x-ray department about the need for airborne precautions is important but not the primary precaution for transporting the client.

C reason:

Wearing a filtration mask and gloves by the nurse during transport is protective for the nurse but does not prevent the client from spreading the infection during transport.

D reason:

Asking the x-ray technician to come to the client's room for a portable x-ray can be considered but is not always practical. The primary focus is ensuring the client wears a mask during transport to minimize infection risk to others.

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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

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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