Nokea
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the exhibit.
- A. Jugular venous distention (JVD)
- B. Systolic murmur
- C. Irregular pulse
- D. Widened pulse pressure
Correct Answer: C
Rationale: An irregular ECG tracing, such as in atrial fibrillation, typically correlates with an irregular pulse due to inconsistent ventricular contractions.
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The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 58-year-old male client.
Item 1 of 1
History & Physical Vital Signs Laboratory
Physician: >
1600: 58-year-old client with a history of hypertension and diabetes mellitus (type one) reports headaches and elevated blood pressure. The client reported the headaches started one day ago and have worsened. The client reports not taking his prescribed medications because he lost his health insurance. His prescribed antihypertensive medications were clonidine and enalapril. The client has a flushed appearance on exam, endorses a generalized headache, and blurred vision.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Administer prescribed timolol ophthalmic
- B. Obtain hourly blood glucose levels
- C. Obtain a prescription for regular insulin infusion
- D. Position the client Semi-fowler's
- E. Administer prescribed nitroprusside
- F. Potential Conditions: Hypertensive Emergency
- G. Blood Pressure, Thiocyanate levels
Correct Answer: D,E,F,G
Rationale: The client is likely experiencing a hypertensive emergency due to elevated BP, headache, and blurred vision. Actions: E - Nitroprusside lowers BP rapidly; D - Semi-Fowler's position reduces cardiac workload. Parameters: Blood Pressure monitors treatment efficacy; Thiocyanate levels ensure nitroprusside safety.
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will need to take antibiotics for one week following this test.
- B. This test will determine if I have any blood clots in my heart.
- C. I will receive general anesthesia for this procedure.
- D. I may feel a flushing sensation when the contrast dye is given.
Correct Answer: B
Rationale: TEE is used to detect intracardiac thrombi, such as in atrial fibrillation, making this statement correct.
The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
The nurse is caring for a client with cardiac tamponade. Which vital signs are expected?
- A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
- B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
- C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
- D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
Correct Answer: A
Rationale: Cardiac tamponade causes tachycardia (HR >100), increased respiratory rate, and hypotension due to restricted cardiac output.
The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as
- A. a widened pulse pressure.
- B. a pulse deficit.
- C. pulsus paradoxus.
- D. an expected finding.
Correct Answer: B
Rationale: A difference between apical and radial pulses indicates a pulse deficit, often due to weak or missed beats.