A client comes to the emergency department with complaints of chest pain after using cocaine. The nurse assesses the client and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing?
Sinus bradycardia
Ventricular tachycardia
Normal sinus rhythm
Sinus tachycardia
The Correct Answer is D
A. Sinus bradycardia is characterized by a heart rate below 60 beats/min, which is inconsistent with this client’s elevated heart rate of 128.
B. Ventricular tachycardia is a potentially life-threatening rhythm with wide QRS complexes, usually not the immediate expected rhythm without other signs such as hypotension or loss of consciousness.
C. Normal sinus rhythm has a heart rate between 60–100 beats/min; this client’s rate of 128 exceeds that range.
D. Sinus tachycardia is the most likely rhythm, especially in a client who has used cocaine, a stimulant known to increase sympathetic nervous system activity, leading to increased heart rate and elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The presence of prosthetic heart valves is a significant risk factor for infective endocarditis due to the increased likelihood of bacterial colonization.
B. Sedentary lifestyle is not a direct risk factor for infective endocarditis, though it may contribute to other cardiovascular issues.
C. Radiation exposure – While it may affect cardiac tissue, it is not considered a risk factor for infective endocarditis.
D. Cardiac catheterization – While it is an invasive procedure, it is not a major or common risk factor for infective endocarditis compared to prosthetic valves or structural heart defects.
Correct Answer is D
Explanation
A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
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