While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
Check temperature and SPO2
Report the rate to the primary care provider
Check the pulse again in 2hrs
Record the information
The Correct Answer is A
A. Check temperature and SPO2
When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.
B. Report the rate to the primary care provider:
Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.
C. Check the pulse again in 2 hours:
Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.
D. Record the information:
Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:
mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL
Plugging in the values from the question, we get:
mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL
Simplifying the equation, we get:
mL to administer = 60 mEq x 15 mL / 20 mEq
mL to administer = 45 mL
Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.
Correct Answer is A
Explanation
A. Take the blood pressure:
Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.
B. Remove the pillow from under the patient’s head:
Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.
C. Elevate the foot of the bed:
Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.
D. Elevate the head of the bed:
Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.
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