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 C
Explanation
A. Hypoglycemia: Hypoglycemia, or low blood sugar, is not typically associated with hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the blood. While both conditions can occur due to certain diseases or medication use, they are not directly related.
B. Hyperreflexia: Hyperreflexia, a condition characterized by overactive reflexes, is not a common symptom of hypokalemia. Hypokalemia primarily affects muscle function, leading to symptoms such as muscle weakness, cramps, and potentially cardiac dysrhythmias. It does not typically cause an overactive reflex response.
C. Cardiac dysrhythmias: This is correct. Hypokalemia can lead to cardiac dysrhythmias. Potassium plays a crucial role in maintaining normal electrical activity in the heart. When potassium levels are low, it can disrupt this electrical activity, leading to irregular heart rhythms.
D. Increased appetite: Increased appetite is not a typical symptom of hypokalemia. In fact, loss of appetite is more commonly associated with this condition. Severe hypokalemia can affect the functioning of the muscles in the digestive system, leading to symptoms such as bloating, constipation, and abdominal pain.
Correct Answer is D
Explanation
A. Insert the IV catheter:
Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.
B. Obtain a blood sample:
Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.
C. Attach the leads for a 12-lead ECG:
Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.
D. Initiate oxygen therapy:
Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.
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