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 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.
Correct Answer is D
Explanation
A. Sepsis is a general systemic infection that can arise from many sources but is not the specific concern addressed by prophylactic antibiotics in valve replacement patients.
B. Otitis media (middle ear infection) is unrelated to dental or surgical procedures and not a concern in valve replacement clients.
C. Deep vein thrombosis (DVT) is prevented with anticoagulants and mobility, not antibiotics.
D. Bacterial endocarditis is a serious infection of the heart's inner lining or valves. Clients with valve replacements are at increased risk, especially during procedures like dental work that may introduce bacteria into the bloodstream. Antibiotic prophylaxis is essential to prevent this potentially life-threatening condition.
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