The nurse is caring for a client with a resting heart rate of 120 beats/minute. Which nursing intervention would be the highest priority in plan of care?
A) Arrange periods of activity with periods of rest.
B) Instruct to sit on the edge of the bed before rising.
C) Place a pillow under the feet and ankles.
D) Maintain strict intake and output.
B
Feedback:
Safety is always a high priority. Instructing the client to sit on the edge of the bed before rising helps to prevent falls related to hypotension and dizziness. Cardiac output drops dangerously low in clients with tachycardia due to the client's heart not having sufficient time to fill with blood. Alternating periods of rest with periods of activity and maintaining strict intake and output are appropriate nursing interventions but not the highest priority. Placing a pillow under the feet and ankles is used for individuals with edema where the nurse wants to improve venous blood return.
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