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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.
Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.
Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.
Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.
Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.
Correct Answer is D
Explanation
The Heelis not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The coccyx, or tailbone, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The Occiput, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
he breasts, particularly in female clients, can experience significant pressure when in the prone position. Using a small pillow can help to relieve this pressure and increase the client’s comfort.A small pillow can help support the client’s breasts and prevent them from being compressed or injured during the prone position1.The breasts are a sensitive area that can be affected by gravity, friction, or pressure2.A pillow can also help maintain proper body alignment and prevent hyperextension of the back
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