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 A
Explanation
Acceptable identifiers for patients in healthcare include the patient’s full name, date of birth, medical record number, and telephone number12. These identifiers are used to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual.
Correct Answer is C
Explanation
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
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