The nurse is caring for a client who is two weeks post-op hip replacement and has a wound infection. The client's admission vital signs are: Temperature 102 F (38.8 C) orally, HR 150/min (rhythm is shown below). Respiratory rate- 22/min, and Blood pressure is 128/72. Based on these assessment findings, the nurse understands that the client:
surgery has caused an episode of supraventricular tachycardia.
is febrile which is causing the heart rate to be elevated.
is in heart failure and the heart rate is elevated to compensate.
probably has a low oxygen saturation causing an increased respiratory rate.
The Correct Answer is B
A. surgery has caused an episode of supraventricular tachycardia: While stress or surgery can trigger arrhythmias, the ECG shown demonstrates a sinus tachycardia pattern (narrow QRS complexes with identifiable P waves before each QRS), not supraventricular tachycardia (SVT), which typically has a very rapid, regular rhythm often without visible P waves.
B. is febrile which is causing the heart rate to be elevated: The client has a temperature of 102°F (38.8°C), which can increase metabolic demand and lead to sinus tachycardia. Fever is a common and expected cause of elevated heart rate, especially when accompanied by infection, such as the client’s post-op wound infection.
C. is in heart failure and the heart rate is elevated to compensate: There is no evidence from the scenario (no dyspnea, crackles, edema, or reduced BP) that supports heart failure. The elevated HR is more directly related to the fever and infection, not cardiac decompensation.
D. probably has a low oxygen saturation causing an increased respiratory rate: The respiratory rate is slightly elevated (22/min), but there is no mention of hypoxia or oxygen saturation levels. Tachycardia secondary to hypoxia would require clinical indicators of respiratory distress or desaturation, which are not demonstrated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Amiodarone: Amiodarone is a Class III antiarrhythmic that primarily works by blocking potassium channels, thereby prolonging repolarization and the action potential duration. It is used to manage various atrial and ventricular arrhythmias, including atrial fibrillation and ventricular tachycardia.
B. Digoxin: Digoxin is a cardiac glycoside that increases myocardial contractility and slows conduction through the AV node. It does not affect potassium channels directly but rather works by inhibiting the sodium-potassium ATPase pump.
C. Verapamil: Verapamil is a calcium channel blocker (Class IV antiarrhythmic) that slows conduction through the AV node and is used to treat supraventricular tachyarrhythmias and hypertension. It has no significant effect on potassium channels.
D. Carvedilol: Carvedilol is a non-selective beta-blocker with some alpha-blocking effects. It reduces heart rate and blood pressure but does not block potassium channels or have antiarrhythmic properties in that classification.
Correct Answer is B
Explanation
A. calculate the number of small squares between one QRS complex and the next one and divide by 1500: This method provides an accurate heart rate calculation, but it is more time-consuming and typically used when precision is needed. It is not the quickest method for rapid bedside estimation of rate.
B. use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10: This is the fastest and most commonly used method for quickly estimating heart rate on an ECG strip. By counting the QRS complexes in a 6-second interval and multiplying by 10, the nurse gets an approximate beats-per-minute rate.
C. count the number of large squares in the R-R interval and divide by 300: This method also provides a quick estimate of heart rate but is best suited for regular rhythms. If the rhythm is irregular, this approach can yield inaccurate results.
D. print a 1-minute ECG strip and count the number of QRS complexes: While accurate, this method is inefficient for quick bedside estimation and is rarely used in practice for rapid assessment due to the time it takes to obtain and interpret a full-minute strip.
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