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
Answer is B: Write the information at an 8th-grade reading level.
This is the best action for the nurse to take because it ensures that the information is accessible and understandable to a wide audience, which is suitable for the general population¹². The other options are not as effective for the following reasons:
- Use a 12-point font size: This is important for readability, but not enough for comprehension. The font size should also match the layout and design of the brochure.
- Explain medical terminology using basic, one-syllable words: This is a good approach, but it does not address the reading level of the content. The nurse should also use simple sentences and avoid jargon.
- Present information from complex to simple: This might be helpful, but it is not the most effective way to educate the public. The nurse should start with the simpler concepts and gradually build on them to explain the more complex aspects of hypertension.
Correct Answer is D
Explanation
Choice A rationale:
Bradycardia. Heparin is an anticoagulant medication that primarily affects the blood's clotting ability. Bradycardia, or a slow heart rate, is not a common side effect of heparin. Therefore, it is not a typical adverse effect to report in this context.
Choice B rationale:
Anorexia. Anorexia, or a loss of appetite, is not a common adverse effect of heparin. Heparin's primary mode of action is to prevent blood clot formation, and it does not directly affect appetite.
Choice C rationale:
Weight gain. Weight gain is not a typical adverse effect of heparin. Heparin's mechanism of action does not lead to changes in body weight. Weight gain could be related to other factors but is not directly associated with heparin administration.
Choice D rationale:
Epistaxis. Epistaxis, or nosebleeds, can be a sign of a bleeding disorder or an adverse effect of anticoagulant therapy like heparin. Heparin can increase the risk of bleeding, including nosebleeds, and should be monitored closely for this adverse effect. It is important to report any signs of excessive bleeding to the healthcare provider as they may need to adjust the dosage or monitor the patient more closely.
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