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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Free Nursing Study Resources

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.

A. Performs auscultation between meals B. Clamps the Naso Gastric tube during auscultation C. Palpates the abdomen prior to performing auscultation. D. Auscultates bowel sounds for 3 to 5 min

Correct Answer is C

Explanation

A. Performs auscultation between meals:

Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.

B. Clamps the Naso Gastric tube during auscultation

Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.

C. Palpates the abdomen prior to performing auscultation:

Palpating the abdomen before auscultation may interfere with normal bowel sounds

D. Auscultates bowel sounds for 3 to 5 min:

Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.

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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

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

Correct Answer is ["45"]

Explanation

A nursing instructor is observing a nursing student auscultating a client’s bowel sounds. Which of the following actions might require the instructor’s intervention?

Correct Answer is C

Explanation

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