The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

Ask another nurse to verify the pulse rate.

Notify the client's health care provider.

Compare the client's pulse rate to the standard range and trends.

Document the pulse in the appropriate chart page.

Answer and Explanation

The Correct Answer is C

A. Ask another nurse to verify the pulse rate: While verification can be helpful in some situations, it is not the first step in interpreting an abnormal vital sign.

B. Notify the client's health care provider: Immediate notification is appropriate if the pulse rate is critically abnormal and the client is symptomatic. However, assessment and analysis should precede notification.

C. Compare the client's pulse rate to the standard range and trends: The nurse should first analyze the pulse rate in the context of normal ranges (60–100 bpm for adults) and assess any changes or patterns over time to determine clinical significance.

D. Document the pulse in the appropriate chart page: Documentation is necessary but should occur after the nurse has interpreted and assessed the vital sign for possible interventions. Interpretation is a critical part of the nursing process that directly influences further decisions.

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Correct Answer is C

Explanation

A. implementation, planning, evaluation, assessment, and diagnosis: This sequence is incorrect because assessment and diagnosis must precede planning and implementation to establish a foundation for care.

B. diagnosis, implementation, assessment, evaluation, and planning: Diagnosis cannot occur before assessment, and planning must come before implementation, so this order is not correct.

C. assessment, diagnosis, planning, implementation, and evaluation: This is the correct sequence of the nursing process, starting with gathering data, identifying problems, developing care plans, carrying out interventions, and finally assessing outcomes.

D. planning, assessment, diagnosis, evaluation, and implementation: Planning cannot precede assessment and diagnosis; this sequence disrupts the logical order of patient care.

A. double verify with a licensed personnel. B. monitor intake and output. C. assess vital signs. D. give with orange juice to promote absorption.

Correct Answer is A

Explanation

A. double verify with a licensed personnel: Insulin is a high-alert medication with a narrow therapeutic window and a significant risk of causing serious harm if dosed incorrectly, including severe hypoglycemia. Double verification with another licensed healthcare professional ensures accurate dosing and enhances patient safety.

B. monitor intake and output: Monitoring intake and output is important for assessing fluid balance and kidney function but does not directly influence the safe administration of insulin or prevent dosing errors related to blood glucose control.

C. assess vital signs: While vital signs such as heart rate and blood pressure are important in overall patient assessment, they do not directly prevent insulin administration errors or detect hypoglycemia before it occurs.

D. give with orange juice to promote absorption: Orange juice is used to treat hypoglycemia due to its sugar content but does not promote insulin absorption. Insulin absorption is primarily influenced by injection site and technique, not concurrent food or drink intake.

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The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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