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.

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Correct Answer is A

Explanation

Choice A rationale:

"Prednisone can cause blood glucose levels to increase." Rationale: This statement is accurate. Prednisone is a corticosteroid medication known to cause hyperglycemia (high blood glucose levels) as a side effect. It is important for the nurse to monitor the client's blood glucose levels while they are taking prednisone, especially if the client has preexisting diabetes or risk factors for diabetes.

Choice B rationale:

"Older adults are at risk for developing type 1 diabetes mellitus." Rationale: This statement is incorrect. Type 1 diabetes mellitus typically develops in childhood or early adulthood and is characterized by autoimmune destruction of the insulin-producing cells in the pancreas. Older adults are more at risk for developing type 2 diabetes, which is different from type 1 diabetes in terms of its etiology and pathophysiology.

Choice C rationale:

"Having COPD causes blood glucose levels to fluctuate." Rationale: This statement is not accurate. COPD (Chronic Obstructive Pulmonary Disease) primarily affects the respiratory system and does not directly cause blood glucose level fluctuations. Blood glucose levels can be affected indirectly in some cases due to factors like medications or stress associated with the illness, but it is not a direct result of COPD.

Choice D rationale:

"Albuterol treatments can cause blood glucose levels to decrease." Rationale: This statement is not a typical effect of albuterol treatments. Albuterol is a bronchodilator commonly used to treat respiratory conditions like COPD and asthma. It is not known to cause significant decreases in blood glucose levels.

A. Black out the line with a felt-tip pen. B. Leave the space as it is within the entry. C. Draw a horizontal line through the space and sign at the end of the line. D. Place the date at the beginning of the space, followed by double lines.

Correct Answer is C

Explanation

Choice A rationale:

Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.

Choice B rationale:

Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.

Choice C rationale:

Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.

Choice D rationale:

Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily.The client asks why the nurse is checking his blood glucose level.Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is documenting client care in the nurses' notes and notices that a space was left blank.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?