A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

Carotid bruit

Heart murmur

Pulse deficit

Bounding radial pulse

Answer and Explanation

The Correct Answer is C

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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Correct Answer is B

Explanation

A. "Picture yourself in one of your favorite places." This statement is related to visualization, which is a different technique, not specifically meditation.

B. "Choose a word to help focus your attention." Mantra meditation involves repeating a word or phrase to enhance focus and promote relaxation.

C. "Quickly inhale deeply and hold your breath for 30 seconds." Holding the breath for 30 seconds can increase anxiety rather than reduce it. Meditation encourages slow, deep breathing, not breath-holding.

D. "Plan for 1 hour of meditation for each session." Meditation can be beneficial even if done for a few minutes. For beginners, shorter sessions (e.g., 5–10 minutes) are recommended.

A. Client appears anxious B. Mucous membranes cyanotic C. S1, S2 auscultated, no murmur D. Skin warm and dry E. Respiratory rate 27/min F. Oxygen saturation 84% on 3L nasal cannula

Correct Answer is ["A","B","E","F"]

Explanation

Oxygen Saturation: 84% on 3L nasal cannula

The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.

Mucous Membranes Cyanotic

Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.

Respiratory Rate: 27/min (Increased from 22/min)

An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.

Client Appears Anxious

Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

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Correct Answer is B

Explanation

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?