The nurse is caring for a client with a heart rate of 48. His blood pressure is 120/80. Which finding will help the nurse determine the cause of the client's bradycardia?
The client has a fever.
The client has possible hemorrhage or bleeding.
The client has chronic obstructive pulmonary disease (COPD).
The client has calcium channel blocker medicate prescribed.
The Correct Answer is D
A. Fever can cause tachycardia (increased heart rate) rather than bradycardia. It is not typically associated with slowing of the heart rate unless there are other complicating factors such as severe infection or medication side effects.
B. Significant blood loss can lead to hypovolemia (low blood volume), which can result in bradycardia as a compensatory mechanism to maintain blood pressure. However, the blood pressure in this scenario is
normal (120/80), which makes severe hemorrhage less likely unless compensated by fluid resuscitation or other factors.
C. COPD can cause chronic hypoxia and respiratory acidosis, which can lead to chronic respiratory compensation and potentially bradycardia. However, COPD alone is less likely to cause bradycardia in the absence of severe exacerbation or other complicating factors.
D. Calcium channel blockers (CCBs) are medications commonly prescribed for conditions such as hypertension, angina, and arrhythmias. They work by blocking calcium channels in cardiac and smooth muscle cells, resulting in decreased heart rate and vasodilation. Bradycardia is a known side effect of CCBs, especially when taken in excess or in combination with other medications that affect heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B. Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C. Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D. This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.
Correct Answer is D
Explanation
A. Serum sodium levels are typically assessed to evaluate electrolyte balance and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
B. This could be ordered for various reasons such as assessing lung status or identifying any abnormalities in the chest. It is not directly related to monitoring warfarin therapy.
C. BUN levels are measured to assess kidney function and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
D. The INR is a standardized measurement of the blood's ability to clot. Warfarin works by inhibiting vitamin K-dependent clotting factors, thereby prolonging the time it takes for blood to clot. The INR is used to monitor and adjust warfarin dosage to maintain therapeutic anticoagulation levels, especially in patients with conditions like atrial fibrillation who are at risk of blood clots.
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