A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?
S3 heart sounds
Irregular pulsations
Bradycardia
Increase in point of maximum impulse (PMI)
The Correct Answer is B
A) S3 heart sounds:
S3 heart sounds are typically associated with heart failure and are not directly related to premature ventricular contractions (PVCs). S3 heart sounds occur during the early diastolic phase and are heard immediately after S2.
B) Irregular pulsations:
This is the correct choice. Premature ventricular contractions (PVCs) can cause irregular pulsations in the pulse. PVCs are premature contractions originating from the ventricles, which can interrupt the normal rhythm of the heart and lead to irregularities in the pulse.
C) Bradycardia:
Premature ventricular contractions (PVCs) can lead to various rhythm disturbances, but bradycardia (slow heart rate) is not typically associated with PVCs. In fact, PVCs often occur in the context of tachycardia (rapid heart rate).
D) Increase in point of maximum impulse (PMI):
An increase in the point of maximum impulse (PMI) is not typically associated with premature ventricular contractions (PVCs). The PMI refers to the location where the apex of the heart is palpated during systole and is not directly affected by PVCs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A critical pathway for clients who have had a stroke:
Critical pathways are structured multidisciplinary care plans that outline essential steps in the care of patients with specific conditions. While critical pathways are valuable tools for standardized care, they are not specifically focused on health promotion activities for clients with hypertension.
B. Standards of care for monitoring clients who have a history of blood pressure elevation:
Standards of care typically outline the minimum level of care that should be provided to clients based on evidence-based practice. While monitoring clients with a history of blood pressure elevation is important, it does not encompass the comprehensive health promotion activities related to hypertension.
C. Acute care facility protocols for clients experiencing an abrupt change in mental status:
Acute care facility protocols are designed to guide the management of acute changes in a patient's condition. While relevant to patient care, these protocols do not specifically address health promotion activities for clients with hypertension.
D. Clinical practice guidelines for the management of high blood pressure:
Clinical practice guidelines provide evidence-based recommendations for the management of specific health conditions. They typically include information on health promotion activities, risk factor modification, lifestyle interventions, and pharmacological management for clients with hypertension. Therefore, clinical practice guidelines are the most appropriate resource for information on health promotion activities for clients with hypertension.
Correct Answer is D
Explanation
A. Have the client place their head between their knees:
Placing the head between the knees may help alleviate symptoms of hyperventilation by promoting relaxation and reducing dizziness. This position can help increase venous return to the heart and improve cerebral blood flow, which may reduce symptoms associated with hyperventilation.
B. Plan to administer sodium bicarbonate to the client:
Sodium bicarbonate is not indicated for respiratory alkalosis. It is used to treat metabolic acidosis by increasing plasma bicarbonate levels. Administering sodium bicarbonate to a client with respiratory alkalosis may exacerbate the alkalosis by further increasing the pH of the blood.
C. Plan to administer insulin to the client:
Insulin administration is not indicated for respiratory alkalosis. Insulin is used to manage hyperglycemia in diabetes mellitus and does not address the underlying respiratory condition causing alkalosis.
D. Have the client breathe into a paper bag:
Breathing into a paper bag is a common intervention for managing hyperventilation associated with respiratory alkalosis. Rebreathing exhaled carbon dioxide helps increase carbon dioxide levels in the blood, which can reverse the alkalosis and alleviate symptoms of hyperventilation.
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