A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Irregular pulsations

Bounding pulsations

Tachycardia

Bradycardia

Answer and Explanation

The Correct Answer is A

A. Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.

B. Bounding pulsations are not specific to PVCs and are more indicative of conditions like high cardiac output states.

C. Tachycardia is not a direct finding associated with PVCs; PVCs are more about irregular beats rather than a consistently high heart rate.

D. Bradycardia is not typically associated with PVCs; PVCs are characterized by irregular beats but not necessarily a slow heart rate.

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Correct Answer is D

Explanation

A. Dizziness is not a primary finding of right ventricular failure but may be associated with other conditions.

B. Crackles in the lungs are more associated with left ventricular failure.

C. Dry, hacking cough is not a primary symptom of right ventricular failure but may be seen in left-sided heart failure.

D. Hepatomegaly is a common finding in right ventricular failure due to increased pressure in the venous system.

A. Flex the client's hip. B. Hyperextend the client's neck. C. Provide warming measures for the client. D. Adjust the client's head of bed.

Correct Answer is D

Explanation

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

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A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Nursing Test Bank

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