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 A

Explanation

A. Yellow sclera
Yellow sclera indicates jaundice, which could be a sign of liver dysfunction. Both isoniazid and rifampin can cause hepatotoxicity, and monitoring for jaundice is crucial to ensure the safety of the client.

B. Increasing AST level
AST level is slightly elevated but remains in the upper range of normal. Continued monitoring is necessary but may not require immediate reporting unless liver function significantly deteriorates.

C. Weight loss
Weight loss is consistent with the client’s condition and does not necessarily require immediate reporting unless it is severe or unmanageable.

D. Mantoux test result
The Mantoux test result is negative, which may be expected in the early phase of tuberculosis treatment. It should be monitored over time.

E. Increasing ALT level
ALT is slightly elevated but still within normal limits, though it's essential to continue monitoring for trends.

F. Reddish-orange urine color
Reddish-orange urine is a known side effect of rifampin and does not typically require immediate reporting

A. Educate the client that hematuria is expected following the procedure. B. Notify the provider immediately if mucus is present in the urine. C. Monitor hourly urine output. D. Apply skin barrier around the stoma site. E. Maintain the client on a fluid restriction.

Correct Answer is ["A","C","D"]

Explanation

A. Hematuria is commonly expected following an ileal conduit procedure due to the surgical intervention in the urinary tract.
B. Mucus in the urine is a normal finding after an ileal conduit procedure because the ileum secretes mucus naturally; it does not require immediate notification of the provider unless there are other concerning symptoms.
C. Monitoring hourly urine output is crucial to ensure the patency of the urinary system and to detect any early signs of complications such as obstruction or leakage.
D. Applying a skin barrier around the stoma site is essential to protect the skin from the corrosive effects of urine and to prevent skin breakdown.
E. Fluid restriction is not typically required unless specifically indicated by the provider for other medical reasons; maintaining adequate hydration is important for the client's recovery and to ensure proper urine production.

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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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