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 C
Explanation
Opioid toxicity can cause difficulties with breathing and an opioid overdose can lead to death1. A respiratory rate of 10/min is considered low and could be a sign of opioid toxicity.
Correct Answer is B
Explanation
Turning the client to the side can help prevent aspiration while performing oral care on an unconscious patient.
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