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","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.

Correct Answer is D
Explanation
While it is generally recommended to avoid close or prolonged exposure to strong magnetic fields, such as those generated by MRI machines, placing items that generate magnetic fields over the pacemaker/ICD, such as cell phones or certain medical devices, does not typically pose a risk. Therefore, it would be important for the nurse to clarify the client's understanding and provide accurate information about the precautions related to magnetic fields.
The other statements made by the client are generally correct and align with the typical recommendations for individuals with pacemakers/ICDs:
Avoiding contact sports or lifting heavy objects for a specified period of time after pacemaker/ICD insertion is usually advised to allow for proper healing and to reduce the risk of lead dislodgment or damage to the device.
Informing dentists and healthcare providers about the presence of a pacemaker/ICD is important so that they can take appropriate precautions during procedures or treatments that may involve electromagnetic interference or interfere with the device's functioning.
While it is generally advised to avoid close proximity to strong magnetic fields, such as those in airports or certain household appliances, it does not necessarily mean completely avoiding them. The nurse can clarify the specific recommendations regarding metal detectors at airports and the safe use of household appliances.
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