A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect?
Anxiety
Lightheadedness
Elevated temperature
Fluid volume deficit
The Correct Answer is B
A. Anxiety is not a typical finding in bradycardia. However, if bradycardia leads to symptoms like dizziness or hypotension, the patient may experience anxiety as a secondary response.
B. Lightheadedness is a common symptom of bradycardia. When the heart rate is too slow, the body may not pump enough blood to meet its oxygen demands, leading to dizziness or lightheadedness.
C. Elevated temperature is not typically associated with bradycardia. Fever is more likely to be related to infection or other systemic issues, not a slow heart rate.
D. Fluid volume deficit is not directly related to bradycardia. However, bradycardia could contribute to hypotension, which may be exacerbated by fluid volume deficits, but it is not a direct cause of fluid loss.
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Related Questions
Correct Answer is D
Explanation
A. Offering reassurance is important for addressing anxiety, but it is not the immediate priority in this situation. The patient's difficulty in clearing thick respiratory secretions should be addressed first to prevent further complications.
B. Applying humidification to the oxygen may help loosen secretions over time, but it does not provide immediate relief. The priority is to clear the airway to ensure adequate oxygenation and prevent aspiration.
C. Encouraging the patient to increase oral fluid intake is helpful in the long term for thinning secretions, but it does not address the immediate problem of difficulty in coughing up thick secretions.
D. Suctioning the tracheostomy is the priority action. The patient is unable to clear thick secretions, and suctioning is necessary to remove the obstruction and improve airway patency, which will also alleviate anxiety and improve oxygenation.
Correct Answer is A
Explanation
A. Obtaining an ECG is the appropriate action to assess for any changes in the heart's electrical activity that may indicate worsening ischemia or other complications, such as a myocardial infarction. Even though the pain has decreased, it is important to evaluate the underlying cause of the chest pain, particularly with unstable angina.
B. Initiating a peripheral IV is not the priority action unless the client requires immediate medication or fluids. In this case, the primary concern is assessing the cause of the chest pain through an ECG.
C. Administering another nitroglycerin tablet is not appropriate at this point. The client reports a significant reduction in pain (from 6 to 2), indicating that the first dose of nitroglycerin was effective. Administering additional doses without further assessment could be unnecessary and may lead to hypotension.
D. Calling the Rapid Response Team is not indicated at this point, as the client’s condition seems to be improving with the nitroglycerin. The priority action is to assess the client’s condition further with an ECG.
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