Which physical assessment findings would the nurse anticipate for a client with rapid atrial flutter?

Visual changes, anorexia

Polyuria, polydipsia

Palpitations, shortness of breath

Systolic murmur, severe anxiety

Answer and Explanation

The Correct Answer is C

A.   These are not typical symptoms of atrial flutter. They may be seen in other conditions like hypertensive crisis or systemic problems, but not as a primary manifestation of atrial flutter.
B.   These are classic signs of diabetes or hyperglycemia, not atrial flutter.
C.   These are common symptoms of atrial flutter, which results in an irregular heart rhythm and may cause increased heart rate, leading to palpitations and shortness of breath.
D.   A systolic murmur is more associated with valve problems, and anxiety could be a result of various issues but is not a typical finding directly caused by atrial flutter.

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Correct Answer is A

Explanation

A. Cyanosis, or a bluish discoloration of the skin, occurs when there is insufficient oxygen in the blood, which can result from decreased perfusion due to clotting in DIC. It is a sign of poor oxygenation and perfusion.
B. While petechiae (small red or purple spots) are a common manifestation of DIC due to microvascular clotting and bleeding, they are not a sign of decreased perfusion.
C. Epistaxis (nosebleeds) is another bleeding manifestation of DIC but is not indicative of decreased perfusion, which is more closely related to cyanosis.
D. Hematuria (blood in the urine) can occur in DIC due to clotting in the kidneys or urinary tract. However, it is more related to bleeding than to decreased perfusion.

A. Report the findings and anticipate a medical prescription for amiodarone B. Initiate a rapid response call and increase the monitor's sensitivity C. Start compressions and prepare for defibrillation D. Establish unresponsiveness and check the carotid pulse

Correct Answer is D

Explanation

A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL
Calcium	8.0 mg/dL	8.2-10.2 mg/dL:

Which physical assessment findings would the nurse anticipate for a client with rapid atrial flutter?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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