Which is the role of the nurse regarding a malfunctioning IV pump?

Choice A reason: This is the correct choice because the patient’s lung sounds are diminished bilaterally with expiratory wheezes is an example of objective data. Objective data is observable and measurable information that can be verified by the nurse or other health care professionals. The nurse can use a stethoscope to listen to the patient’s lung sounds and document the findings.

Choice B reason: This is an incorrect choice because the patient worries that the insurance company will not pay the hospital bill is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s worry, but can only rely on the patient’s verbal report.

Choice C reason: This is an incorrect choice because the patient wonders if supplemental oxygen at home would be beneficial is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s wonder, but can only rely on the patient’s verbal report.

Choice D reason: This is an incorrect choice because the patient felt less short of breath after receiving a nebulizer treatment is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s feeling, but can only rely on the patient’s verbal report.

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats..