The nurse is assessing a client with a heart rate of 124 bpm. What clinical finding(s) should the nurse assess as causes of tachycardia? Select all that apply.
Blood glucose 90 mg/dL
Pain level of 10 out of 10
Temperature 101.9 F
Hemoglobin: 7g/dl
Cocaine abuse
Correct Answer : B,C,D,E
Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.
Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inflammation.
Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.
Cocaine abuse: Cocaine is a stimulant drug that can significantly increase heart rate and cause tachycardia.
The following clinical finding would not typically be associated with tachycardia:
Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to significant physiological stress or hormonal imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The questions related to the client's history that are most important to ask are:
How would you describe your symptoms?: This question is important to assess the client's current cardiac symptoms and determine the severity, duration, and nature of their symptoms. It helps the nurse to evaluate the client's cardiac status and determine appropriate interventions.
Are you allergic to any medications or foods?: This question is crucial to identify any potential allergies that could impact the client's cardiac care. It helps the nurse ensure that medications and interventions are safe for the client and prevent any adverse reactions.
How did your mother die?:This question is important to gather information about the client's family history of cardiac diseases and potential risk factors. Understanding the family history helps the nurse assess the client's genetic predisposition to cardiac conditions and plan appropriate interventions and screenings.
Have you had shortness of breath or weight gain? : This question is important to assess for symptoms of heart failure or fluid retention. Shortness of breath and weight gain can indicate fluid accumulation, which is a common symptom in cardiac conditions. It helps the nurse evaluate the client's cardiac function and determine the need for furtherinterventions or medication adjustments.
Let's review the other options and explain why they are not the most important questions to ask:
Do you have any children?: While family history is important, specifically asking about children is not as relevant to the client's current cardiac condition. The focus should be on the client's own symptoms, medical history, and family history of cardiac diseases.
Correct Answer is ["A","B","C","D"]
Explanation
Assess pulse of the affected extremity every 15 minutes at first: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood flow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.
Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood flow or other complications that require immediate attention.
Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.
Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood flow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not sufficient if there are concerns regarding blood flow or graft viability.
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