A nurse is caring for a client and auscultates an apical heart rate of 100/min. Which of the following actions should the nurse take?
Call the provider
Prepare the client for a chest x-ray
Ask another nurse to verify the heart rate
Document this as an expected finding
The Correct Answer is D
A reason:
Calling the provider is unnecessary for an apical heart rate of 100/min unless there are other concerning symptoms. This heart rate is within the upper range of normal, especially if the client is active or anxious.
B reason:
Preparing the client for a chest x-ray is not warranted solely based on a heart rate of 100/min. Other clinical indications would be needed to justify this diagnostic test.
C reason:
Asking another nurse to verify the heart rate is not required. A heart rate of 100/min is within the normal range and does not typically necessitate double-checking unless there are irregularities or other concerns.
D reason:
Documenting this as an expected finding is correct. An apical heart rate of 100/min is within the normal range, especially in situations of mild exertion or stress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A reason:
Contact precautions are used to prevent the spread of infections that are transmitted by direct or indirect contact with the patient or the patient's environment. These precautions are not specific to the needs of a client with a stem-cell transplant, who is more susceptible to infections due to a weakened immune system.
B reason:
Airborne precautions are used for infections that can be spread through the air over long distances, such as tuberculosis, measles, and chickenpox. This is not the primary concern for a client with a stem-cell transplant.
C reason:
Neutropenic precautions are correct. These are specific infection-control measures used to protect immunocompromised patients, such as those who have undergone an allogeneic hematopoietic stem-cell transplant. These precautions include measures to prevent infection from external sources because the patient’s immune system is significantly weakened.
D reason:
Droplet precautions are used to prevent the spread of infections that are transmitted through large respiratory droplets, such as influenza or meningitis. While important, these precautions are not tailored to the specific needs of a stem-cell transplant patient, who requires more stringent infection prevention measures.
Correct Answer is B
Explanation
A reason:
Visitors may bring a fruit basket is incorrect. Fresh fruit can carry bacteria and should be avoided.
B reason:
Refraining from bringing flowers is correct. Flowers can carry bacteria and fungi, posing a risk to immunocompromised clients.
C reason:
A sick family member visiting, even with a mask, is incorrect. Sick visitors should avoid contact with immunocompromised clients to prevent infection.
D reason:
All visitors must complete hand washing, but wearing an N95 mask is not necessary unless specifically required. Standard masks are typically sufficient.
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