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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Calculate the total volume to be infused in drops.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
= 1000 mL × 60 gtts/mL
= 60000 gtts
Calculate the total infusion time in minutes.
Total infusion time (minutes) = Total hours × 60 minutes/hour
= 8 hours × 60 minutes/hour
= 480 minutes
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 60000 gtts / 480 minutes
= 125
=125 gtts/min
Correct Answer is ["35"]
Explanation
Calculate the total infusion time in minutes.
Infusion time in minutes = 2 hours × 60 minutes/hour
= 120 minutes
Calculate the total number of drops to be infused.
The total volume remaining is 350 mL
Drip factor is 12 gtts/mL.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
Total drops = 350 mL × 12 gtts/mL
= 4200 gtts
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 4200 gtts / 120 minutes
= 35
=35 gtts/min
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