Question

The nurse is obtaining a set of vital signs. The results indicate an elevated pulse rate. What other information is needed to determine a course of action? Select all that apply. What is the client’s normal baseline pulse rate range? No other information is needed beyond this result in order to take action. Has the client recently been active (walking in the hallway, etc.)? If the client is over the age of 65, this finding would not be of concern as this is typical with this age group. Are there cues in the client’s health status and history that are contributing to this finding? What is the client’s normal baseline pulse rate range? No other information is needed beyond this result in order to take action. Has the client recently been active (walking in the hallway, etc.)? If the client is over the age of 65, this finding would not be of concern as this is typical with this age group. Are there cues in the client’s health status and history that are contributing to this finding?

Answer 1

To determine a course of action for an elevated pulse rate, a nurse must know the client's normal pulse rate, recent activity levels, overall health status, history, and the presence of additional symptoms. Misconceptions about age and heart rate should not overshadow the clinical evaluation. Treatment is based on the underlying cause of the elevated heart rate.

Step-by-step explanation:

When a nurse observes an elevated pulse rate, several pieces of additional information are necessary to determine the appropriate course of action. It's critical to know the client's normal baseline pulse rate since fluctuations from this range could indicate an irregularity. Next, assessing whether the client has been physically active recently is also important, as exercise can temporarily increase the heart rate. Additionally, understanding the client's health status and history is crucial; this includes checking for symptoms such as weakness, fatigue, dizziness, fainting, chest discomfort, palpitations, or respiratory distress, as these may signify that the heart is not delivering enough oxygenated blood to the body.

It's a common misconception that elevated heart rates are normal for individuals over the age of 65; however, an elevated pulse should be evaluated in the context of the individual's overall clinical picture regardless of age. Lastly, examining if the client exhibits other symptoms such as shortness of breath or chest pain is necessary because these could point to a serious condition needing immediate attention. Treatment and intervention will depend on uncovering the underlying cause of the tachycardia.