The nurse is caring for a client who is two weeks post-op hip replacement and has a wound infection. The client's admission vital signs are: Temperature 102 F (38.8 C) orally, HR 150/min (rhythm is shown below). Respiratory rate- 22/min, and Blood pressure is 128/72. Based on these assessment findings, the nurse understands that the client:
surgery has caused an episode of supraventricular tachycardia.
is febrile which is causing the heart rate to be elevated.
is in heart failure and the heart rate is elevated to compensate.
probably has a low oxygen saturation causing an increased respiratory rate.
The Correct Answer is B
A. surgery has caused an episode of supraventricular tachycardia: While stress or surgery can trigger arrhythmias, the ECG shown demonstrates a sinus tachycardia pattern (narrow QRS complexes with identifiable P waves before each QRS), not supraventricular tachycardia (SVT), which typically has a very rapid, regular rhythm often without visible P waves.
B. is febrile which is causing the heart rate to be elevated: The client has a temperature of 102°F (38.8°C), which can increase metabolic demand and lead to sinus tachycardia. Fever is a common and expected cause of elevated heart rate, especially when accompanied by infection, such as the client’s post-op wound infection.
C. is in heart failure and the heart rate is elevated to compensate: There is no evidence from the scenario (no dyspnea, crackles, edema, or reduced BP) that supports heart failure. The elevated HR is more directly related to the fever and infection, not cardiac decompensation.
D. probably has a low oxygen saturation causing an increased respiratory rate: The respiratory rate is slightly elevated (22/min), but there is no mention of hypoxia or oxygen saturation levels. Tachycardia secondary to hypoxia would require clinical indicators of respiratory distress or desaturation, which are not demonstrated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. the heart rate is greater than 100 bpm in sinus tachycardia: Normal Sinus Rhythm is characterized by a heart rate between 60 and 100 beats per minute (bpm). Sinus tachycardia is defined as a sinus rhythm with a heart rate exceeding 100 beats per minute. The rhythm remains regular, with each P wave followed by a QRS complex, but the rate is significantly faster than normal sinus rhythm.
B. more p waves are present than QRS complexes: In sinus tachycardia, the number of P waves and QRS complexes remains one-to-one, as each atrial impulse continues to be conducted to the ventricles. More P waves than QRS complexes typically suggest atrial flutter or other forms of AV dissociation.
C. the QRS complexes measure greater than 0.10: A widened QRS complex suggests a bundle branch block or ventricular rhythm, not sinus tachycardia. In sinus tachycardia, QRS complexes typically remain narrow, measuring less than 0.10 seconds unless an intraventricular conduction delay is present.
D. the rhythm is often irregular in sinus tachycardia: Sinus tachycardia is usually a regular rhythm with consistent R-R intervals. An irregular rhythm is more indicative of atrial fibrillation or sinus arrhythmia, not a defining characteristic of sinus tachycardia.
Correct Answer is ["200"]
Explanation
Volume ordered is 1 L.
Convert the total volume to milliliters (mL)
1 L = 1000 mL.
Total volume in mL = 1 L × 1000 mL/L = 1000 mL
Total infusion time = 5 hours
Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total infusion time (hours)
= 1000 mL / 5 hours
= 200
The appropriate setting is 200 mL/hr.
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