A nurse is assessing a client who has a heart rate of 56/min.
Which of the following findings should the nurse expect?
Temperature of 39°C (102.2°F).
History of cigarette smoking.
Report of dizziness.
Hypoglycemia.
The Correct Answer is C
Choice A rationale:
A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.
Choice B rationale:
History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.
Choice C rationale:
A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.
Choice D rationale:
Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Material safety data sheets (MSDS) primarily contain information related to hazardous chemicals and substances used in healthcare settings. While MSDS can be valuable for safety purposes, they do not provide comprehensive information on specimen collection protocols. Therefore, MSDS is not the most appropriate source for revising the specimen collection protocol.
Choice B rationale:
Client medical records are essential for individual patient care and documentation. However, they do not contain the information needed to revise the protocol for specimen collection on the unit. Medical records are specific to individual patient histories, diagnoses, and treatments, and do not address broader unit-wide protocols.
Choice C rationale:
Facility policy and procedures are the most appropriate source for retrieving information to revise the protocol for specimen collection on the unit. These policies and procedures are specifically designed to guide healthcare providers in delivering safe and effective care within the facility. They encompass standardized protocols for various clinical procedures, including specimen collection, making them the ideal source for the nurse's research.
Choice D rationale:
Evidence-based practice (EBP) involves using the best available research evidence, clinical expertise, and patient values to guide healthcare decisions. While EBP is crucial in healthcare, it is not the primary source for revising unit-specific protocols. EBP provides a broader framework for making clinical decisions but may not cover the specific policies and procedures unique to the facility.
Correct Answer is A
Explanation
Choice A rationale:
Skilled nursing is the most appropriate resource to anticipate for a postoperative client who needs physical therapy 2-3 times per day for two weeks. Skilled nursing facilities provide care from licensed nurses and therapists, making them well-suited for short-term rehabilitation and therapy services. These facilities offer a higher level of medical care compared to the other options, ensuring that the client's postoperative needs are adequately met.
Choice B rationale:
Assisted living is not the most suitable option for a postoperative client who requires physical therapy multiple times a day. Assisted living facilities are generally designed for individuals who need assistance with daily activities but do not require constant medical or therapeutic interventions.
Choice C rationale:
Long-term care is not the appropriate choice for a postoperative client with a two-week prescription for physical therapy. Long-term care facilities are designed for individuals who require ongoing, extended care, often due to chronic illnesses or disabilities. The client's condition is temporary, so long-term care is not warranted.
Choice D rationale:
Palliative care is intended for clients with serious, life-limiting illnesses, focusing on pain management and improving the quality of life. It is not suitable for a postoperative client who needs physical therapy for a limited duration. The primary goal of palliative care is different from the client's needs in this scenario.
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