The nurse observes a patient with a heart rate of 120 bpm and reports of dizziness. What is the nurse's next action?
Administer IV fluids to stabilize heart rate
Assess vital signs and check for underlying causes.
Encourage the patient to left and rest
Notify the provider immediately.
The Correct Answer is B
A. Administer IV fluids to stabilize heart rate: IV fluids may be indicated if hypovolemia is suspected, but giving fluids without assessing the underlying cause could be inappropriate and potentially harmful. Assessment must guide interventions.
B. Assess vital signs and check for underlying causes: A heart rate of 120 bpm with dizziness could indicate tachycardia due to dehydration, infection, arrhythmia, anemia, or other causes. Assessing vital signs, oxygen saturation, and possible contributing factors is the priority to guide safe and targeted interventions.
C. Encourage the patient to lie and rest: While resting may temporarily relieve symptoms, it does not address the underlying cause. Immediate rest alone does not ensure patient safety if the tachycardia is due to a serious condition.
D. Notify the provider immediately: Provider notification may be necessary after assessment, but the nurse must first gather critical information to report, including vital signs, symptoms, and potential causes, to ensure effective communication and safe care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide the spouse with educational materials about the client's condition: Offering information is helpful for understanding the client’s condition, but it does not directly address the spouse’s emotional state or demonstrate empathy. Emotional support requires acknowledgment of feelings.
B. Ask direct questions about their silence to get a response: Pressuring the spouse to speak may increase anxiety and inhibit communication. Empathy involves creating a safe, nonjudgmental space rather than forcing disclosure.
C. Focus on the client's needs and address the spouse's concerns later: Ignoring the spouse’s emotional cues can lead to feelings of isolation and distress. Providing support in the moment is essential for family-centered care.
D. Acknowledge the spouse's feelings by saying it seems like this situation might be overwhelming for you. What can I do to help?: This approach validates the spouse’s emotions and invites dialogue in a supportive way. It demonstrates empathy, encourages trust, and allows the nurse to respond to emotional needs while maintaining sensitivity to the family’s experience.
Correct Answer is B
Explanation
A. Apply a moisturizing cream immediately: Moisturizing creams are not sterile and can introduce bacteria to an open wound. They do not prevent infection and may delay proper healing if applied directly to an abrasion.
B. Cover the abrasion with a dry, sterile bandage: Using a sterile dressing protects the wound from environmental contaminants, reduces the risk of infection, and promotes healing. Maintaining a clean barrier is a primary intervention for infection prevention in open skin injuries.
C. Use a scented lotion to cover the abrasion: Scented lotions contain chemicals that can irritate the wound and are not sterile, increasing the risk of infection. They are not appropriate for open abrasions.
D. Leave the abrasion open to air: While some minor abrasions may heal with exposure, leaving a wound uncovered increases the risk of contamination and infection. A sterile covering is safer, especially for larger or deeper abrasions.
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