The client with ischemic heart disease has an ECG tracing that shows first-degree heart block. What is the nurse's best first action?
A. Document the finding as the only action.
B. Measure blood pressure.
C. Notify the physician.
D. Administer oxygen.
B
First-degree heart block in a stable client requires no intervention. The nurse must establish whether the client is hemodynamically stable. Measuring blood pressure can establish that the client is stable.
You might also like to view...
Hospital administrators are applying the principles of evidence-based practice (EBP) in their attempt to ascertain the most efficient and effective way to communicate
between nurses who are on different units, a project that will consider many types of evidence. Which of the following information sources should the administrators prioritize? A) A systematic review about communication in nursing contexts B) Nurses' ideas about communication methods C) The results of a chart review D) The hospital's accreditation status
The most common symptom of osteoarthritis is
A. deformity. B. pain. C. weakness. D. spasticity.
The nurse is reviewing the nature of personality disorders with a client. Which client statement indicates that teaching has been effective?
1. "The disorder started when I was 5." 2. "The disorder does not interfere with functioning." 3. "My symptoms will escalate over time." 4. "My disorder began in my early adulthood."
The nurse identifies a wellness nursing diagnosis for a pregnant patient. What should the nurse identify as the goal for this diagnosis?
A) Identify potential problems B) Identify acute health problems C) Identify chronic health problems D) Identify the potential for improvement in health