He nurse observes that a client's pulse rate is 58 beats per ...

[pragya sharda]

he nurse observes that a client's pulse rate is 58 beats per minute and regular in rhythm. Which of the following statements made by the nurse shows the appropriate understanding of the client's further need for assessment?
 
  1. I'll wait 15 minutes and reevaluate the client's pulse rate.
  2. Her pulse rate is usually in the mid 60s, so there isn't a problem.
  3. I'll need to assess her for the presence of chest pain and/or dizziness.
  4. You run an electrocardiogram, and I'll notify her health care provider.

Question 2

The nurse is assessing a client with a history of chronic obstructive pulmonary disease. When as-sessing for the presence of air hunger, the nurse should:
 
  1. Monitor the client's pulse oximetry reading
  2. Measure the movement of air by counting respirations
  3. Auscultate breath sounds both anteriorly and posteriorly
  4. Observe for the elevation of the client's clavicles during inspiration

[ju]

Answer to Question 1

ANS: 3
A low but regular heart rate has no clinical significance unless associated with signs and symp-toms of reduced cardiac output such as dizziness or syncope or the presence of chest pain.

Answer to Question 2

ANS: 4
During an assessment, observe for elevation of the client's clavicles during inspiration. Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Although the remaining options are assessment methods, they are not as effective for determining air hunger.

[pragya sharda]

Thank you!

[ju]

Always glad to help...