The nurse is obtaining vital signs for a client in the clinic who has had a cardiac transplant. The nurse obtains an apical heart rate of 110 beats/minute. What is a priority action by the nurse?
A) Obtain an electrocardiogram.
B) Notify the physician.
C) No action is required because the transplanted heart beats faster than the natural heart.
D) Administer a calcium channel blocker to decrease the heart rate.
C
Feedback:
The transplanted heart beats faster than the client's natural heart, averaging about 100 to 110 beats/minute, because nerves that affect heart rate have been severed. The new heart also takes longer to increase the heart rate in response to exercise. If the client is asymptomatic, there is no reason to obtain an ECG or notify the physician. The nurse would not administer the calcium channel blocker without a physician's order.
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