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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) Develop client-specific goals and outcomes: While this is an important step in the nursing process, it is not the first step. Before developing goals and outcomes, the nurse needs to understand the client’s situation, which in this case involves determining the nature of the client’s grief.
(B) Incorporate the treatment into the client’s care: Incorporating treatment into the client’s care is part of the implementation phase of the nursing process. Before this step, the nurse needs to assess the client’s condition and plan the care, which includes understanding the nature of the client’s grief.
(C) Determine whether coping strategies were successful: Determining the success of coping strategies is part of the evaluation phase of the nursing process. This is typically done after the implementation of care and treatment. It is not the first step in caring for a client experiencing grief.
(D) Establish whether the client’s grieving is healthy or complicated: This is the most appropriate answer. The first step in the nursing process is assessment. For a client experiencing grief, this would involve establishing whether the client’s grieving is healthy (a normal response to loss) or complicated (prolonged or more intense grief that may require additional support or intervention). This understanding will guide the subsequent steps of the nursing process, including planning care and setting goals.
Correct Answer is B
Explanation
(A) Bradycardia: Bradycardia, or a slower than normal heart rate, is not typically associated with metabolic acidosis. Metabolic acidosis often leads to an increased heart rate (tachycardia) as the body tries to compensate for the acid-base imbalance.
(B) Hyperventilation: This is the most appropriate answer. Hyperventilation is a common response to metabolic acidosis. The body attempts to compensate for the high acid levels by increasing the rate and depth of breathing to expel more carbon dioxide (which is acidic) and raise the blood pH.
(C) Increased blood pressure: Metabolic acidosis does not typically cause an increase in blood pressure. In fact, severe acidosis can lead to vasodilation and a decrease in blood pressure.
(D) Cool, clammy skin: While cool, clammy skin can be a sign of shock or other serious conditions, it is not a typical manifestation of metabolic acidosis. However, in severe cases, metabolic acidosis can lead to shock, which might present with cool, clammy skin.
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