A nurse is collecting data on a client who has a heart rate of 44/min.
Which of the following findings should the nurse expect?

Temperature of 39°C (102.2°F)

History of cigarette smoking.

Patient reports they feel that they are going to pass out.

Hypoglycemia.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Temperature of 39°C (102.2°F) A temperature of 39°C (102.2°F) is elevated, but it is not directly related to a heart rate of 44/min. Elevated temperature can be caused by various factors, such as infection, and would not be an expected finding solely due to the heart rate.

Choice B rationale:

History of cigarette smoking. A history of cigarette smoking may be a risk factor for certain cardiovascular conditions, but it does not directly explain a heart rate of 44/min. The heart rate can be influenced by factors such as medications, cardiac conditions, and autonomic nervous system activity.

Choice D rationale:

Hypoglycemia. Hypoglycemia (low blood sugar) can cause various symptoms, including shakiness, confusion, and sweating, but it is not the primary cause of a heart rate of 44/min. Hypoglycemia is more likely to cause symptoms related to altered mental status and autonomic nervous system activation.

Choice C rationale:

Patient reports they feel that they are going to pass out. A heart rate of 44/min is significantly lower than the normal range for adults, which is typically between 60-100 beats per minute. Such a low heart rate, known as bradycardia, can lead to decreased blood flow to vital organs, including the brain. Feeling like they are going to pass out is a concerning symptom associated with bradycardia because it suggests inadequate cardiac output and perfusion. This finding should prompt immediate assessment and intervention to address the underlying cause of the slow heart rate.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.

A. "Let's discuss this when we have more time.” B. "I wouldn't worry about this right now. C. "I can't imagine how difficult it would be to lose my hair.” D. "I will get you information about some head-covering options.” L. t's focus on your chemotherapy.”

Correct Answer is D

Explanation

Choice A rationale:

Delaying the discussion about managing hair loss when the client has expressed concern is not the best approach. The nurse should provide information and support when the client seeks it.

Choice B rationale:

Discouraging the client from worrying about hair loss at this moment is not empathetic. The client's concerns should be acknowledged and addressed.

Choice C rationale:

Expressing empathy and relating to the client's emotional experience is a good practice, but it does not directly answer the client's question about managing hair loss.

Choice D rationale:

Offering to get information about head-covering options indicates an understanding of the client's concerns and provides a proactive solution. It shows empathy and willingness to support the client during chemotherapy, where hair loss can be a significant emotional issue.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data on a client who has a heart rate of 44/min.Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is to begin chemotherapy.The client asks the nurse about managing hair loss.Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information.Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

A nurse is collecting data on a client who has a heart rate of 44/min.
Which of the following findings should the nurse expect?