The nurse is assessing a client with a heart rate of 124 bpm. What clinical finding(s) should the nurse assess as causes of tachycardia? Select all that apply.
Blood glucose 90 mg/dL
Pain level of 10 out of 10
Temperature 101.9 F
Hemoglobin: 7g/dl
Cocaine abuse
Correct Answer : B,C,D,E
Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.
Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inflammation.
Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.
Cocaine abuse: Cocaine is a stimulant drug that can significantly increase heart rate and cause tachycardia.
The following clinical finding would not typically be associated with tachycardia:
Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to significant physiological stress or hormonal imbalances.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Absent bilateral pedal pulses indicate a potential vascular complication, such as impaired circulation or blood flow to the lower extremities. It may suggest compromised perfusion and could be a sign of arterial occlusion or thrombosis, which requires immediate intervention. The nurse should notify the healthcare provider promptly to assess the client's condition and initiate appropriate interventions to restore circulation to the lower extremities.
While complaints of pain at the site of the incision are significant, post-operative pain is expected after abdominal surgery. The nurse should assess the pain and provide appropriate pain management interventions, but it may not require immediate intervention unless the pain is severe or accompanied by other concerning symptoms.
A distended, tender abdomen could indicate various post-operative complications, such as bowel obstruction or peritonitis. Although it should be evaluated and reported to the healthcare provider, it may not require immediate intervention unless the client's condition deteriorates or other signs of a surgical emergency are present.
An elevated temperature of 100°F (37.8°C) alone, without other signs of infection or systemic complications, may not necessarily require immediate intervention. It could be a normal response to surgery or a mild post-operative infection. The nurse should monitor the client's temperature and assess for other signs of infection, and if necessary, report it to the healthcare provider for further evaluation.
Correct Answer is A
Explanation
The information that the nurse should include in the teaching plan for a client with hypertension who is on alpha blockers and at risk for postural hypotension is: Change positions slowly.
Alpha blockers are a class of medications commonly prescribed for hypertension. One potential side effect of alpha blockers is postural hypotension, which is a sudden drop in blood pressure when changing positions, such as from sitting to standing. To minimize the risk of postural hypotension, it is important for the client to change positions slowly. The nurse should advise the client to take their time when transitioning from lying down, sitting, or standing, allowing their body to adjust and stabilize their blood pressure.

The other options are not appropriate or helpful in managing postural hypotension:
Check blood pressure every day for signs of rebound hypertension: Rebound hypertension refers to a sudden increase in blood pressure that can occur when discontinuing certain antihypertensive medications. It is not directly related to postural hypotension. Regular blood pressure monitoring is important for managing hypertension, but it is not specifically related to postural hypotension or alpha blockers.
Do not become dependent on canes, walkers, or handrails: Assistive devices like canes, walkers, or handrails can provide support and stability for individuals who experience balance issues or are at risk of falls. It is not necessary to discourage their use unless there are specific contraindications or safety concerns.
Eat plenty of salty food to prevent hypotension: Increasing salt intake is generally not recommended for individuals with hypertension or those at risk of postural hypotension. A high-sodium diet can contribute to elevated blood pressure and is generally discouraged. The nurse should instead encourage a balanced diet that includes appropriate sodium intake based on the client's healthcare provider's recommendations.
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