A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?
a. Assess the patient for causes of tachycardia.
b. Take an apical heart rate and compare the two.
c. Document the findings in the patient's chart.
d. Notify the patient's health care provider.
ANS: A
Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or fluid volume alterations. The nurse should assess the patient thoroughly for possible causative factors. Since the pulse is regular, there is no reason to take an apical pulse. The findings should be documented, but the nurse needs to do more. The provider may or may not need to be notified, depending on the outcome of the nurse's assessment.
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