A client who was discharged from the hospital 2 days ago after having a permanent pacemaker placed presents to the emergency department with sharp chest pain and difficulty breathing. Which assessment findings require the highest priority intervention?

BP 105/70 manually & flat neck veins

Equal breath sounds with a respiratory rate of 28

Distended neck veins & muffled heart sounds

Heart rate 105 & respiratory rate of 28

Answer and Explanation

The Correct Answer is C

A. BP 105/70 manually & flat neck veins: This blood pressure is within a low-normal range, and flat neck veins suggest no evidence of right-sided heart failure or cardiac tamponade. Though the patient needs evaluation, these findings are not emergent.

B. Equal breath sounds with a respiratory rate of 28: A mildly elevated respiratory rate can indicate distress, but equal breath sounds suggest the absence of pneumothorax or hemothorax. While the patient is symptomatic, this finding alone doesn't demand the most urgent intervention.

C. Distended neck veins & muffled heart sounds: These are classic signs of cardiac tamponade, a life-threatening emergency that can occur due to pacemaker lead perforation. This condition results in fluid accumulation in the pericardial sac, impairing cardiac output and requiring immediate intervention such as pericardiocentesis.

D. Heart rate 105 & respiratory rate of 28: These are signs of physiological compensation and indicate stress or early decompensation. However, without signs like neck vein distention or muffled heart sounds, they are less critical than the findings in option C.

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Correct Answer is B

Explanation

A. surgery has caused an episode of supraventricular tachycardia: While stress or surgery can trigger arrhythmias, the ECG shown demonstrates a sinus tachycardia pattern (narrow QRS complexes with identifiable P waves before each QRS), not supraventricular tachycardia (SVT), which typically has a very rapid, regular rhythm often without visible P waves.

B. is febrile which is causing the heart rate to be elevated: The client has a temperature of 102°F (38.8°C), which can increase metabolic demand and lead to sinus tachycardia. Fever is a common and expected cause of elevated heart rate, especially when accompanied by infection, such as the client’s post-op wound infection.

C. is in heart failure and the heart rate is elevated to compensate: There is no evidence from the scenario (no dyspnea, crackles, edema, or reduced BP) that supports heart failure. The elevated HR is more directly related to the fever and infection, not cardiac decompensation.

D. probably has a low oxygen saturation causing an increased respiratory rate: The respiratory rate is slightly elevated (22/min), but there is no mention of hypoxia or oxygen saturation levels. Tachycardia secondary to hypoxia would require clinical indicators of respiratory distress or desaturation, which are not demonstrated.

A. Benign Prostatic Hyperplasia B. Congestive Heart Failure C. Rheumatic Fever D. Coronary Artery Disease

Correct Answer is A

Explanation

A. Benign Prostatic Hyperplasia: Tamsulosin is an alpha-1 adrenergic blocker specifically prescribed to relieve urinary symptoms caused by benign prostatic hyperplasia (BPH). It works by relaxing the smooth muscles in the bladder neck and prostate, improving urine flow and decreasing bladder outlet obstruction.

B. Congestive Heart Failure: Tamsulosin is not indicated for heart failure management. Medications used in heart failure typically include ACE inhibitors, beta blockers, diuretics, and aldosterone antagonists not selective alpha-1 blockers like tamsulosin.

C. Rheumatic Fever: Rheumatic fever is linked to valvular heart disease, not urinary retention or prostate enlargement. Tamsulosin does not have a role in its treatment or management.

D. Coronary Artery Disease: Tamsulosin does not have any therapeutic effect in managing coronary artery disease. CAD is typically managed with medications such as beta blockers, statins, antiplatelets, and nitrates, depending on the clinical scenario.

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A client who was discharged from the hospital 2 days ago after having a permanent pacemaker placed presents to the emergency department with sharp chest pain and difficulty breathing. Which assessment findings require the highest priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is administering tamsulosin to a client. Which disease process should the nurse expect to find in the client's past medical history?

Correct Answer is A

Explanation

The nurse is caring for a client immediately following the insertion of a permanent pacemaker. Which intervention should be included in the plan of care?

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