A nurse is assessing a client's radial pulse and finds it to be 50 beats per minute. What action should the nurse take?

Correct Answer: A

Rationale: A pulse of 50 can be normal, especially in fit individuals, and should be documented unless symptomatic. Monitoring is premature without distress. Tachycardia doesn't apply. Beta-blockers lower pulse, not needed here. Choice A is correct, per the explanation, reflecting nursing judgment based on context.

Correct Answer: B

Rationale: Tachycardia is likely with fever, infection, and pain, per the answer key, as the heart speeds up to meet metabolic demands. Bradycardia contradicts this. Dysrhythmia or bigeminal suggest irregularity, not rate increase. Nurses expect this response in acute stress states.

Correct Answer: A

Rationale: Health assessment data forms the basis for the nursing process , per the answer key, guiding diagnosis, planning, and care. Illustrating competence or facilitating caring are secondary benefits, not primary uses. Medical care involves physicians, not nursing focus. Nurses rely on this systematic approach, per Taylor, to prioritize patient needs and interventions effectively.

Correct Answer: C

Rationale: Pulling the pinna down and back , per the answer key, straightens the ear canal in children under 3. Up and back is for adults, others (A, D) ineffective. Nurses, per Taylor, adjust for pediatric anatomy.