A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?
Check the client’s heart rate for 30 seconds.
Palpate the client’s pulse at the third intercostal space.
Ask the client to perform the Valsalva maneuver.
Auscultate the client’s apical pulse.
The Correct Answer is D
When caring for a client who has an irregular heart rate, the nurse should auscultate the client’s apical pulse to accurately assess their heart rate1. An electrocardiogram (ECG or EKG) may also be used to measure the timing and duration of each electrical phase in the heartbeat
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
Correct Answer is D
Explanation
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
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