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.

Answer and Explanation

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

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Correct Answer is C

Explanation

The nurse should expect to find an increased heart rate in a client with a fever. An elevated body temperature can cause an increase in metabolic rate, which can lead to an increase in heart rate. This is a normal physiological response to fever and helps the body to generate heat and fight oﬀ infection.

A. A client who has haemorrhoids B. A client who had recent oral surgery C. A client who has a coagulation disorder D. A client who is drinking ice water

Correct Answer is A

Explanation

Answer: A

Rationale:

A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.

B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.

C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.

D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.

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A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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