A nurse is monitoring a post-surgical client who is exhibiting a pulse of 120 beats per minute. What is the most appropriate nursing action?
Notify the provider immediately and prepare for potential intervention,
Reassess the pulse in one hour and document the findings
Perform a manual pulse check and compare it with the monitor reading
Administer pain medication to decrease the pulse rate
The Correct Answer is C
A. Notify the provider immediately and prepare for potential intervention: While tachycardia may signal complications such as bleeding or infection, immediate notification without verification may be premature. The nurse should first confirm the accuracy of the reading.
B. Reassess the pulse in one hour and document the findings: Waiting an hour before reassessment risks delaying recognition of a potentially serious complication. Tachycardia post-surgery warrants prompt verification and assessment rather than delayed monitoring.
C. Perform a manual pulse check and compare it with the monitor reading: Verifying the heart rate manually ensures accuracy and helps identify false readings due to artifact, movement, or monitor malfunction. This is the safest initial action before determining further interventions.
D. Administer pain medication to decrease the pulse rate: Tachycardia may be caused by pain, but it could also indicate hypovolemia, infection, or other post-surgical complications. Administering medication without assessment could mask symptoms and delay treatment of the underlying cause.
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Related Questions
Correct Answer is D
Explanation
A. Administering antipyretics immediately: Treating fever is important for comfort and preventing complications, but it does not address the patient’s immediate threat of hypoxia or respiratory distress. Fever management is secondary to airway and oxygenation.
B. Taking a detailed medical history: Gathering history is important for diagnosis and treatment planning, but it does not immediately relieve respiratory compromise. Delaying interventions for history could endanger the patient.
C. Administering intravenous fluids: IV fluids may be necessary for hydration or shock management, but they do not directly improve oxygenation in acute respiratory distress. Fluid administration is not the first priority unless signs of hypoperfusion are present.
D. Initiating oxygen therapy: Oxygen therapy directly addresses hypoxemia and respiratory distress, which are life-threatening conditions. Ensuring adequate oxygenation is the first priority according to the ABCs (Airway, Breathing, Circulation) of emergency care.
Correct Answer is B
Explanation
A. Delegate the procedure to another nurse without further inquiry: Delegation without verifying scope of practice, competency, or legal guidance can lead to unsafe care and potential legal consequences. Nurses must ensure that the delegatee is qualified before assigning tasks.
B. Refer to the state's Nurse Practice Act for guidance: The Nurse Practice Act defines the legal scope of nursing practice in that state, including what procedures a nurse is authorized to perform and the requirements for competence. Consulting it ensures safe, lawful, and professional decision-making.
C. Perform the procedure to avoid delaying care: Performing a procedure without knowledge or competency violates the Nurse Practice Act and ethical standards, placing both the client and nurse at risk. Immediate action should not override legal and safety considerations.
D. Refuse to perform the procedure without explanation: While refusal is safer than performing an unfamiliar procedure, failure to communicate or seek guidance is unprofessional. The nurse should provide rationale and follow appropriate protocols to maintain client safety.
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