Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?
A. Check the client’s heart rate for 30 seconds.
B. Palpate the client’s pulse at the third intercostal space.
C. Ask the client to perform the Valsalva maneuver.
D. Auscultate the client’s apical pulse.
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
This question is an excerpt from Nurse Dive's nursing test bank - NURS 100 fundamentals swami test 14.18.23 proctored exam. Take the full exam now
Full Explanation
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
Similar Questions
A nurse is planning care for a group of clients. Which of the following clients should the nurse see first?
A. A client who has a spinal cord injury.
A. A client who has a spinal cord injury. While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
B. A client who is unconscious. An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
C. A client who has peripheral vascular disease. Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
D. A client who has a new ankle sprain. A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
E. None
None
F. None
None
Full Explanation
Answer: B. A client who is unconscious.
A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
A. Decrease the head of the client’s bed.
B. Encourage the client to take deep breaths.
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
C. Ask the client to cough every 4 hr.
D. Request a prescription for an opioid analgesic.
Full Explanation
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?
A. Indirect contact
The client acquired the infection through indirect contact transmission by touching a contaminated towel. Indirect contact transmission occurs when a person comes into contact with an object or surface that has been contaminated with infectious agents.
B. Vector
C. Droplet
D. Airborne
Full Explanation
The client acquired the infection through indirect contact transmission by touching a contaminated towel. Indirect contact transmission occurs when a person comes into contact with an object or surface that has been contaminated with infectious agents.