A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
P wave touching the T wave
Midsternal chest pain
Increased urine output
Mild orthostatic hypotension
The Correct Answer is B
A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.
B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.
C. Increased urine output is not an urgent concern in this context.
D. Mild orthostatic hypotension is not as urgent as chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cleaning the skin and clipping hairs ensures good electrode contact, which is essential for accurate ECG readings. This is the correct statement.
B. Oxygen should not be turned off unless specifically instructed by a provider. It does not interfere with ECG monitoring.
C. Electrodes should be placed on the anterior chest for standard ECG monitoring, not on the posterior chest.
D. Electrodes for ECG monitoring typically come with adhesive backing and do not require additional gel.
Correct Answer is B
Explanation
A. Base deficit (HCO3): Acidosis: A base deficit indicates metabolic acidosis, but respiratory acidosis is more likely with the high rate of ventilation.
B. Acid excess (CO2): Acidosis: This is the correct answer. A high respiratory rate can lead to hyperventilation, decreasing CO2 levels and causing respiratory alkalosis, which may be a concern with an elevated rate.
C. Base excess (HCO3): Alkalosis: This would indicate metabolic alkalosis, but it is not as related to ventilator settings.
D. Acid deficit (CO2): Alkalosis: If the CO2 level is too low due to hyperventilation, this can lead to alkalosis, which the nurse is questioning here.
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