The nurse is caring for a client with a heart rate of 48. His blood pressure is 120/80. Which finding will help the nurse determine the cause of the client's bradycardia?
The client has a fever.
The client has possible hemorrhage or bleeding.
The client has chronic obstructive pulmonary disease (COPD).
The client has calcium channel blocker medicate prescribed.
The Correct Answer is D
A. Fever can cause tachycardia (increased heart rate) rather than bradycardia. It is not typically associated with slowing of the heart rate unless there are other complicating factors such as severe infection or medication side effects.
B. Significant blood loss can lead to hypovolemia (low blood volume), which can result in bradycardia as a compensatory mechanism to maintain blood pressure. However, the blood pressure in this scenario is
normal (120/80), which makes severe hemorrhage less likely unless compensated by fluid resuscitation or other factors.
C. COPD can cause chronic hypoxia and respiratory acidosis, which can lead to chronic respiratory compensation and potentially bradycardia. However, COPD alone is less likely to cause bradycardia in the absence of severe exacerbation or other complicating factors.
D. Calcium channel blockers (CCBs) are medications commonly prescribed for conditions such as hypertension, angina, and arrhythmias. They work by blocking calcium channels in cardiac and smooth muscle cells, resulting in decreased heart rate and vasodilation. Bradycardia is a known side effect of CCBs, especially when taken in excess or in combination with other medications that affect heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is not a compensatory mechanism for metabolic acidosis. In fact, during metabolic acidosis, the kidneys excrete hydrogen ions (acid) and reabsorb bicarbonate (base) to help normalize the pH of the blood.
B. Increased urinary output (polyuria) is not typically a direct compensatory response to metabolic acidosis. However, metabolic acidosis can lead to osmotic diuresis in certain conditions, which may increase urinary output as the body tries to excrete excess acids and maintain electrolyte balance.
C. Increased thirst (polydipsia) and hunger (polyphagia) are not typical compensatory responses to metabolic acidosis. These symptoms are more associated with hyperglycemia in diabetes rather than acid-base disturbances.
D. During metabolic acidosis, the respiratory system compensates by increasing the rate and depth of respirations (hyperventilation). By blowing off more CO2 (carbon dioxide), the body tries to decrease the
amount of carbonic acid in the blood, thereby increasing the pH towards normal. This compensatory mechanism helps to raise the pH back towards the normal range (7.35-7.45).
Correct Answer is ["B","C","E"]
Explanation
A. A back massage (A) can be soothing and may help with circulation, but it's not typically a priority immediately postoperative.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques empower the client to actively participate in their comfort and recovery process.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) due to shallow breathing. Coughing and deep breathing exercises help to expand lung volume, clear secretions, and prevent respiratory complications. It's important to encourage and assist the client in performing these exercises regularly.
D. Encouraging the client to turn every 4 hours helps prevent pressure ulcers and promotes good circulation, but turning might be more frequent depending on the surgery and the client's condition.
E. Pain management is crucial for postoperative comfort and recovery. Administering analgesics as needed helps to control pain effectively, which is essential for the client to participate in activities such as deep breathing, coughing, and moving, thereby reducing the risk of complications.
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