A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

Carotid bruit

Heart murmur

Pulse deficit

Bounding radial pulse

Answer and Explanation

The Correct Answer is C

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.

Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.

Incorrect answers;

Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.

Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.

Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.

Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

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