A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?

S3 heart sounds

Irregular pulsations

Bradycardia

Increase in point of maximum impulse (PMI)

Answer and Explanation

The Correct Answer is B

A) S3 heart sounds:
S3 heart sounds are typically associated with heart failure and are not directly related to premature ventricular contractions (PVCs). S3 heart sounds occur during the early diastolic phase and are heard immediately after S2.

B) Irregular pulsations:
This is the correct choice. Premature ventricular contractions (PVCs) can cause irregular pulsations in the pulse. PVCs are premature contractions originating from the ventricles, which can interrupt the normal rhythm of the heart and lead to irregularities in the pulse.

C) Bradycardia:
Premature ventricular contractions (PVCs) can lead to various rhythm disturbances, but bradycardia (slow heart rate) is not typically associated with PVCs. In fact, PVCs often occur in the context of tachycardia (rapid heart rate).

D) Increase in point of maximum impulse (PMI):
An increase in the point of maximum impulse (PMI) is not typically associated with premature ventricular contractions (PVCs). The PMI refers to the location where the apex of the heart is palpated during systole and is not directly affected by PVCs.

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Correct Answer is B

Explanation

(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.

(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.

(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.

(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.

A. Abdominal pain B. Lethargy C. Dry skin D. Numbness of fingers

Correct Answer is B

Explanation

A. Abdominal pain: Abdominal pain is not typically associated with respiratory acidosis. Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide, resulting in an acidic blood pH.

B. Lethargy: Lethargy is a common symptom of respiratory acidosis. Patients may experience fatigue, especially during the daytime1. This is due to the increased carbon dioxide levels in the blood, which can cause confusion, drowsiness, and fatigue

C. Dry skin: Dry skin is not a common symptom of respiratory acidosis. The condition primarily affects the respiratory system and does not typically cause skin changes.

D. Numbness of fingers: While numbness of fingers can be a symptom of various conditions, it is not typically associated with respiratory acidosis. The primary symptoms of respiratory acidosis are related to increased carbon dioxide levels in the blood, such as lethargy and confusion.

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A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?

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