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

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should monitor the client for pneumothorax and lead dislodgement following permanent pacemaker placement.

Rationale

Pneumothorax: The procedure involves central venous access, often via the subclavian vein, which increases the risk of puncturing the pleura and causing a pneumothorax. Signs include:

Lead dislodgement: Movement or tension on the pacing lead can result in loss of pacemaker capture or failure to pace effectively. This is a priority during the first 24 hours. Indicators include:

A. Maintaining strict bed rest B. Administering pain medication C. Monitoring vital signs frequently D. Assisting with daily hygiene

Correct Answer is C

Explanation

A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

What is the nurse's priority when caring for a patient in septic shock?

Correct Answer is C

Explanation

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