A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Bradycardia

Tachycardia

Dysrhythmia

Bigeminal

Answer and Explanation

The Correct Answer is B

Choice A reason: Bradycardia (pulse <60 bpm) is unlikely, as fever, infection, and pain increase sympathetic nervous system activity, elevating heart rate. Infection triggers cytokine release, and pain stimulates adrenaline, both increasing cardiac output to meet metabolic demands. Bradycardia would contradict the physiological stress response, making this incorrect for this scenario.

Choice B reason: Tachycardia (pulse >100 bpm) is likely due to fever, infection, and pain activating the sympathetic nervous system. Fever increases metabolic rate, infection induces inflammatory cytokines, and pain releases adrenaline, all elevating heart rate to enhance oxygen delivery. This physiological response matches the client’s condition, making tachycardia the correct pulse type.

Choice C reason: Dysrhythmia involves irregular heart rhythms, like atrial fibrillation, not directly caused by fever, infection, or pain. These conditions increase heart rate via sympathetic stimulation, not necessarily rhythm irregularity. Dysrhythmias require specific cardiac issues, unlike the expected tachycardia from systemic stress, making this incorrect for the client’s presentation.

Choice D reason: Bigeminal pulse (paired beats) indicates a specific arrhythmia, not typically caused by fever, infection, or pain. These conditions elevate heart rate through sympathetic activation and cytokine release, leading to tachycardia, not patterned beats. Bigeminal rhythms require cardiac-specific issues, making this an unlikely pulse type in this systemic stress scenario.

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Correct Answer is C

Explanation

Choice A reason: Labeling the action as libel, a felony, is incorrect, as libel involves defamatory statements, not clinical errors. Negligence relates to failing to meet care standards, not legal defamation. This mischaracterizes the issue, focusing on legal terms irrelevant to the failure to report critical hypertension, per nursing liability.

Choice B reason: While poor interprofessional communication may have contributed, it does not fully capture the negligence. The primary issue is not reporting a critical blood pressure (202/122), which a prudent nurse would address. Communication is secondary to the nurse’s failure to act on a life-threatening finding, per professional standards.

Choice C reason: Failing to act as a prudent nurse under similar circumstances defines negligence, as not reporting 202/122 mmHg endangered the patient, leading to ICU transfer. A reasonable nurse would have notified the provider, preventing harm, aligning with legal and ethical standards of care and accountability.

Choice D reason: Not reassessing blood pressure is relevant but not the core negligence. The primary issue is failing to report the critical reading, which required immediate action. Reassessment alone would not address the urgency of notifying the provider, making this less comprehensive than negligence, per standards.

A. Dysrhythmia B. Tachycardia C. Bradycardia D. Normal pulse

Correct Answer is B

Explanation

Choice A reason: Dysrhythmia refers to an irregular rhythm, not a specific rate. An apical pulse of 140 indicates a fast rate, not necessarily irregular, so tachycardia is more accurate. Dysrhythmia requires evidence of irregularity, not present here, per cardiac assessment terminology.

Choice B reason: Tachycardia is an apical pulse above 100 bpm, and 140 fits this definition, indicating a rapid heart rate. This requires further investigation for causes like pain or hypoxia, ensuring accurate documentation and intervention, per cardiovascular assessment and clinical terminology standards.

Choice C reason: Bradycardia is a pulse below 60 bpm, not applicable to 140. This rapid rate indicates tachycardia, not a slow heart, requiring different management. Mislabeling as bradycardia could lead to inappropriate care, per cardiac physiology and documentation guidelines.

Choice D reason: A normal pulse is 60-100 bpm, not 140. This rate indicates tachycardia, a pathological finding needing evaluation. Documenting as normal ignores a significant abnormality, risking delayed intervention, per clinical standards for pulse rate assessment and documentation.

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A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse pulls a new nurse to the side to discuss documenting a patient’s blood pressure of 202/122 mmHg without reporting it. The patient is now in the ICU. How does the charge nurse best explain how this reflects negligence?

Correct Answer is C

Explanation

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

Correct Answer is B

Explanation

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