A client's radial heart rate suddenly increases from 82 to 112 beats/minute with a 1+ pulse volume. Which assessment should the nurse complete next?

Urinary output.

Pedal pulses.

Heart sounds.

Blood pressure.

Answer and Explanation

The Correct Answer is D

A. Urinary output: Although decreased cardiac output can affect renal perfusion and lower urine output, it is not the immediate assessment after a sudden change in heart rate and pulse quality. Urine output trends over hours, not minutes, making it less useful for acute evaluation.

B. Pedal pulses: Pedal pulses assess peripheral circulation but are not as responsive to acute changes in central perfusion. Diminished pedal pulses may suggest poor perfusion, but the sudden rise in heart rate with weak radial pulse should prompt central hemodynamic assessment first.

C. Heart sounds: Heart sounds provide information about valve function and rhythm but may not detect subtle changes in perfusion status. While auscultation is important, it does not immediately quantify the impact of tachycardia and diminished pulse strength on blood pressure and perfusion.

D. Blood pressure: Assessing blood pressure is the most direct and immediate way to evaluate hemodynamic stability in the setting of sudden tachycardia with a weak pulse. Hypotension may indicate decreased cardiac output or early shock, requiring prompt recognition and intervention.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Bilateral tinnitus when initially standing up: Tinnitus is not a common or serious adverse effect of nitroglycerin. While it may indicate another underlying issue, such as hypertension or ototoxicity, it is not immediately life-threatening.

B. Dizziness when rising from the bedside: Dizziness can result from the vasodilatory effects of nitroglycerin causing orthostatic hypotension. It is relatively common and usually managed with safety precautions and monitoring rather than immediate reporting.

C. Hypotension with a systolic of 90 mm Hg: A systolic blood pressure of 90 mm Hg is concerning after nitroglycerin administration, as the drug significantly lowers preload and can precipitate hemodynamic instability. This finding requires prompt HCP notification to prevent complications such as syncope or myocardial underperfusion.

D. Onset of headache after administration: Headache is a well-known and expected side effect of nitroglycerin due to cerebral vasodilation. While uncomfortable, it is generally benign and does not warrant immediate reporting unless it becomes severe or unrelenting.

A. Epigastric distress B. Occurring without cause C. Pain only relieved by opioids D. Feelings of fear E. Chest pain radiating down arm F. Pain relived by nitroglycerin

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"B"}}

Explanation

Epigastric distress: Epigastric discomfort can occur in both angina and myocardial infarction due to referred pain or visceral irritation from ischemia. Clients may confuse this with indigestion, particularly in atypical presentations.
Occurring without cause: Myocardial infarction pain often occurs suddenly and unpredictably, including during rest or sleep. It is not always precipitated by physical exertion or emotional stress, unlike classic stable angina.
Pain only relieved by opioids: Myocardial infarction pain is severe and typically not responsive to nitroglycerin alone. Relief often requires opioid analgesics like morphine, which also help reduce cardiac workload.
Feelings of fear: A sense of impending doom or intense anxiety is commonly reported in both angina and myocardial infarction, likely due to sympathetic nervous system activation during cardiac distress.
Chest pain radiating down arm: Radiation of pain, especially to the left arm, is classic in both angina and myocardial infarction. It reflects the shared neural pathways between the heart and upper extremity.
Pain relieved by nitroglycerin: Angina is typically responsive to rest and nitroglycerin, which dilates coronary arteries and reduces oxygen demand. In contrast, MI pain often persists despite nitroglycerin.

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A client's radial heart rate suddenly increases from 82 to 112 beats/minute with a 1+ pulse volume. Which assessment should the nurse complete next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers a sublingual nitroglycerin tablet to a client with unstable angina. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"B"}}

Explanation

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