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

Answer and Explanation

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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Correct Answer is C

Explanation

A reason:

Airborne precautions are not required for VRE. These precautions are used for infections transmitted through the air, such as tuberculosis, which is not the case with VRE.

B reason:

Protective precautions (also known as neutropenic or reverse precautions) are used to protect immunocompromised patients from infections. They are not appropriate for preventing the spread of VRE.

C reason:

Contact precautions are correct. VRE is typically transmitted through direct or indirect contact with contaminated surfaces or infected body fluids. Contact precautions help prevent the spread of VRE to other patients and healthcare workers.

D reason:

Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. VRE is not transmitted in this manner, so droplet precautions are not necessary.

A. Patients with droplet diseases such as measles require an N95 mask. B. I will always wash my hands with soap and water, not hand sanitizer, if I provide care to patients with C. diff, norovirus, and rotavirus infections. C. I will make sure that any patient who is in droplet precaution wears a surgical mask when being transported. D. I will always wear a gown and gloves when entering a room of a patient in contact precautions.

Correct Answer is A

Explanation

A reason:

Patients with droplet diseases such as measles require re-education. Measles is an airborne disease, not droplet, and requires airborne precautions, including an N95 mask.

B reason:

Washing hands with soap and water, not hand sanitizer, for C. diff, norovirus, and rotavirus is correct. These infections require thorough hand washing to remove spores effectively.

C reason:

Ensuring patients in droplet precaution wear a surgical mask when being transported is correct. This helps to prevent the spread of infectious droplets.

D reason:

Wearing a gown and gloves when entering a room of a patient in contact precautions is correct. This prevents the spread of infections through direct and indirect contact.

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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?

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