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

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Client reports feeling dizzy when sitting up from a supine position.

Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.

B. Client reports feeling palpitations when rising from a supine to a standing position.

Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.

C. Erythema is present on the bilateral lower extremities.

Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.

D. The client has a temperature of 100.4 F.

Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.

E. The client states, “I feel lightheaded when sitting up.”

Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.

A. Validate the finding B. Document the finding C. Inform the surgeon D. Inform the charge nurse

Correct Answer is A

Explanation

A. Validate the finding:

Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.

B. Document the finding:

Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.

C. Inform the surgeon:

If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.

D. Inform the charge nurse:

Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.

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While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is A

Explanation

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