HESI Registered Nurse EXIT Practice Exam

After a client undergoes a cardioversion and has a respiratory rate of 12, what action should the nurse take first?

1. Try to vigorously stimulate normal breathing

2. Ask the RN to assess the vital signs

3. Measure the pulse oximetry

4. Continue to monitor respirations

The correct answer is: Continue to monitor respirations

In the scenario of a client who has just undergone cardioversion and exhibits a respiratory rate of 12, the appropriate first action is to continue monitoring respirations. This is a critical response because a respiratory rate of 12 breaths per minute is on the lower end of the normal range for adults, which is typically between 12 to 20 breaths per minute. Monitoring the patient's respiratory status allows the nurse to gauge any changes in the client’s condition following the procedure, as cardioversion can cause temporary alterations in respiratory patterns due to sedation or the effects of the procedure itself. By choosing to continue monitoring respirations, the nurse can observe for any deterioration or stability in the client’s respiratory function, ensuring that appropriate interventions can be initiated if necessary. Evaluating the ongoing status is fundamental in maintaining patient safety and effective care post-procedure. The other options, while they may seem relevant, are not prioritized in this immediate post-cardioversion context. There is little benefit in attempting to stimulate breathing if the respiratory rate has not reached a critical level. Additionally, asking another RN to assess vital signs may delay other actions that could be taken by the current nurse, while measuring pulse oximetry, important as it provides information about oxygen levels,