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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The procedure uses electrical energy to destroy areas of the conduction system: Catheter ablation is a minimally invasive procedure performed to treat abnormal heart rhythms, such as atrial ﬂutter. During the procedure, a catheter is inserted into the heartand used to deliver electrical energy to speciﬁc areas of the heart tissue. This energy is used to destroy or ablate the abnormal conduction pathways that are causing the atrial ﬂutter.

Let's go through the other options and explain why they are not accurate:

The procedure stimulates the growth of new pathways between the atria: Catheter ablation does not stimulate the growth of new pathways. Instead, it aims to eliminate or modify existing abnormal pathways in the heart to restore normal electrical conduction.

The procedure uses cold therapy to stop the formation of the ﬂutter waves: Catheter ablation does not use cold therapy. It primarily utilizes radiofrequency energy or other sources of heat to ablate the targeted areas of the heart tissue.

The procedure prevents or minimizes the patient's risk for sudden cardiac death: While catheter ablation can be an effective treatment for certain arrhythmias, including atrial ﬂutter, it is not primarily performed to prevent or minimize the risk of sudden cardiac death. Its main purpose is to restore normal heart rhythm and alleviate symptoms associated with the arrhythmia.

A. "Make an appointment with the dietitian for teaching.” B. "Check your blood pressure at home at least once a day." C. "Increase your dietary intake of high-potassium foods.” C. "Move slowly when moving from lying to sitting to standing.” D. "Move slowly when moving from lying to sitting to standing.”

Correct Answer is C

Explanation

Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor medication commonly used to treat hypertension. One of the potential side effects of ACE inhibitors is hyperkalemia, which is an elevated level of potassium in the blood. Therefore, it is generally recommended for patients taking ACE inhibitors to avoid excessive intake of high-potassium foods.

The charge nurse should intervene because advising the client to increase their dietary intake of high-potassium foods contradicts the precautions associated with taking enalapril. Consuming high-potassium foods while taking this medication can potentially lead to an increased risk of hyperkalemia, which can have serious health consequences.

Let's review the other statements made by the nurse:

"Make an appointment with the dietitian for teaching": This is an appropriate statement as it encourages the client to seek professional guidance on dietary management of hypertension. A dietitian can provide valuable information on healthy eating habits and strategies to reduce blood pressure.

"Check your blood pressure at home at least once a day": This is also an appropriate statement as it promotes self-monitoring of blood pressure, which is important for clients with hypertension. Regular monitoring helps the client track their progress and detect any changes that may require medical attention.

"Move slowly when moving from lying to sitting to standing": This is a correct statement as it advises the client to practice orthostatic precautions. ACE inhibitors, including enalapril, can cause orthostatic hypotension, a drop in blood pressure upon standing. Moving slowly can help prevent dizziness and falls.

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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.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with atrial ﬂutter who is scheduled for a catheter ablation? What should the nurse include in the teaching plan?

Correct Answer is D

Explanation

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a client with hypertension who has a new prescription for enalapril (Vasotec). Which statement of the nurse to the patient would require the charge nurse's intervention?

Correct Answer is C

Explanation

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