The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?

Do not touch the patient until the assessment is completed.

Inform the patient that she is counting respirations.

Obtain the rate without the patient knowing.

Estimate respirations.

Answer and Explanation

The Correct Answer is C

Choice A reason: Not touching the patient until assessment completion is unnecessary, as gentle touch may be required to feel pulse or position the patient. Avoiding touch does not ensure accurate respiratory assessment and may hinder observation of chest movement, per respiratory assessment guidelines.

Choice B reason: Informing the patient that respirations are being counted may alter their breathing pattern due to awareness, leading to inaccurate rates. Conscious breathing can increase or decrease the rate, compromising the assessment’s validity, per clinical observation techniques.

Choice C reason: Obtaining respirations without the patient knowing ensures an accurate rate, as awareness can cause altered breathing. Discreetly counting while appearing to check the pulse preserves natural respiration, aligning with standard assessment techniques for reliable respiratory rate data, per nursing practice.

Choice D reason: Estimating respirations is inappropriate, as it lacks precision, risking inaccurate data. Counting respirations for 30-60 seconds provides an objective rate, critical for identifying abnormalities like tachypnea or bradypnea, ensuring proper clinical decision-making, per respiratory assessment standards.

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Correct Answer is B

Explanation

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

A. This action is consistent with libel, a felony criminal action. B. There was poor interprofessional communication with the healthcare team. C. You failed to act as a reasonably prudent nurse would under similar circumstances. D. You did not re-assess your patient’s blood pressure.

Correct Answer is C

Explanation

Choice A reason: Labeling the action as libel, a felony, is incorrect, as libel involves defamatory statements, not clinical errors. Negligence relates to failing to meet care standards, not legal defamation. This mischaracterizes the issue, focusing on legal terms irrelevant to the failure to report critical hypertension, per nursing liability.

Choice B reason: While poor interprofessional communication may have contributed, it does not fully capture the negligence. The primary issue is not reporting a critical blood pressure (202/122), which a prudent nurse would address. Communication is secondary to the nurse’s failure to act on a life-threatening finding, per professional standards.

Choice C reason: Failing to act as a prudent nurse under similar circumstances defines negligence, as not reporting 202/122 mmHg endangered the patient, leading to ICU transfer. A reasonable nurse would have notified the provider, preventing harm, aligning with legal and ethical standards of care and accountability.

Choice D reason: Not reassessing blood pressure is relevant but not the core negligence. The primary issue is failing to report the critical reading, which required immediate action. Reassessment alone would not address the urgency of notifying the provider, making this less comprehensive than negligence, per standards.

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The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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