A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Irregular pulsations

Bounding pulsations

Tachycardia

Bradycardia

Answer and Explanation

The Correct Answer is A

A. Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.

B. Bounding pulsations are not specific to PVCs and are more indicative of conditions like high cardiac output states.

C. Tachycardia is not a direct finding associated with PVCs; PVCs are more about irregular beats rather than a consistently high heart rate.

D. Bradycardia is not typically associated with PVCs; PVCs are characterized by irregular beats but not necessarily a slow heart rate.

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Correct Answer is D

Explanation

A. Increasing the rate to 250 mL/hr is not appropriate as it could lead to fluid overload or worsen the client’s condition.

B. Slowing the rate to 20 mL/hr may be too low for maintaining adequate hydration or treatment needs in the context of a head injury.

C. Slowing the rate to 50 mL/hr is not indicated unless there is a specific reason to decrease the fluid rate based on clinical conditions, which is not stated here.

D. Continuing the rate at 125 mL/hr is appropriate for maintaining the current IV fluid regimen unless there are specific orders or conditions that require a change.

A. Place the client in a supine position. B. Use log rolling to reposition the client. C. Place a warming blanket on the client. D. Instruct the client to cough and deep breathe.

Correct Answer is B

Explanation

A. Placing the client in a supine position can increase ICP. The head of the bed should be elevated 30-45 degrees to promote venous drainage from the head.
B. Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
C. A warming blanket is not typically necessary unless the client is hypothermic; it does not directly affect ICP management.
D. Instructing the client to cough and deep breathe can increase ICP and should be avoided in clients with elevated ICP.

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A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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