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

Answer and Explanation

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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Correct Answer is C

Explanation

A. The rule regarding portability of health insurance coverage: This provision addresses the ability to maintain health insurance when changing jobs or coverage, and is unrelated to unauthorized access of patient records.

B. The Security Rule regarding administrative safeguards: The Security Rule focuses on protecting electronic health information through administrative, physical, and technical measures. While security is involved, the primary issue here is unauthorized disclosure, not system safeguards.

C. The Privacy Rule regarding patient authorization and disclosure: HIPAA’s Privacy Rule governs the use and disclosure of protected health information. Accessing a patient’s electronic health record without consent violates the requirement that patients authorize who can view or use their information.

D. The rule concerning breach notification requirements: Breach notification addresses required reporting after a confirmed compromise of PHI. The student’s unauthorized access is a violation of privacy, not a post-breach reporting issue.

A. Document the findings and notify the healthcare provider. B. Increase the frequency of dressing changes. C. Clean the wound with sterile saline and apply a new dressing D. Reassess the wound for additional signs of infection later in the shift.

Correct Answer is A

Explanation

A. Document the findings and notify the healthcare provider: Purulent drainage is a clear sign of infection and may indicate a need for prompt medical intervention, such as antibiotics. The nurse’s first action should be to notify the provider and document the findings to ensure timely, appropriate care.

B. Increase the frequency of dressing changes: While changing the dressing may help manage drainage, it does not address the underlying infection or the need for provider-directed treatment. Immediate notification is more critical.

C. Clean the wound with sterile saline and apply a new dressing: Maintaining wound hygiene is important, but it should follow assessment and provider notification. Acting first without notifying the provider may delay necessary treatment.

D. Reassess the wound for additional signs of infection later in the shift: Delaying assessment could allow the infection to worsen. Immediate documentation and communication with the provider are essential to prevent complications.

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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?

Nursing Test Bank

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