The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis?

A. "If I take my blood pressure and it is normal, I don't have to take my blood pressure pills": This statement reflects a misunderstanding of hypertension management. Blood pressure medications are typically prescribed to help control blood pressure over the long term, regardless of individual blood pressure readings. Stopping medication without consulting a healthcare provider can be dangerous and is not recommended.

B. "When getting up from bed, I will sit for a short period before standing up": This statement demonstrates an understanding of orthostatic hypotension prevention, which is important for clients with hypertension and can be a side effect of certain medications.

C. "I will consult a dietician to help get my weight under control": This statement indicates the client's awareness of the importance of weight management in hypertension control and is a positive step toward healthy lifestyle changes.

D. "I think I'm going to sign up for a yoga class twice a week to help reduce my stress": This statement shows the client's proactive approach to stress reduction, which is beneficial for hypertension management as stress can contribute to elevated blood pressure.

A. Remove the client's IV access:

Removing the client's IV access is not the most appropriate initial action when a client experiences difficulty breathing and severe chest tightness during a transfusion. While it's important to discontinue the infusion, the immediate priority is to stop the transfusion itself to prevent further reaction and assess the client's condition.

B. Assess the client's chest sounds and vital signs:

This choice is the correct answer. After stopping the transfusion, the nurse should assess the client's respiratory status by listening to chest sounds for any wheezing or crackles, as well as checking vital signs such as oxygen saturation, respiratory rate, blood pressure, and heart rate. These assessments help evaluate the severity of the reaction and guide further interventions.

C. Notify the client's healthcare provider:

Notifying the healthcare provider is an essential step, but it typically follows the immediate action of stopping the transfusion and assessing the client's condition. The healthcare provider needs to be informed promptly about the client's condition, transfusion reaction, and the actions taken for further guidance and orders.

D. Stop the transfusion immediately:

This is the initial and most critical action when a client experiences signs of a transfusion reaction such as difficulty breathing and severe chest tightness. Stopping the transfusion promptly helps prevent the reaction from worsening and allows for immediate assessment and intervention to ensure client safety.