The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Anxiety

Sleep

Fever

Hyperglycemia

Blood loss

Answer and Explanation

Correct Answer : A,C,E

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

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Correct Answer is B

Explanation

A. "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls":

This statement is incorrect. High-density lipoprotein (HDL) is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream and transport it to the liver for processing. A decreased HDL level is associated with an increased risk of cardiovascular disease, not with moving cholesterol away from artery walls.

B. "Increased LDL and decreased HDL increase my risk of coronary artery disease":

This statement is correct. Low-density lipoprotein (LDL) is often referred to as "bad" cholesterol because elevated LDL levels contribute to the buildup of plaque in the arteries, increasing the risk of coronary artery disease (CAD). Conversely, decreased HDL levels are associated with reduced cholesterol removal from the bloodstream, further increasing the risk of CAD.

C. "Increased LDL has the potential to decrease my risk of heart disease":

This statement is incorrect. Elevated LDL levels are a major risk factor for heart disease and are associated with an increased risk of atherosclerosis and cardiovascular events.

D. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls":

This statement is incorrect. Increased LDL levels contribute to the deposition of cholesterol on artery walls, leading to the formation of plaque and narrowing of the arteries, which is detrimental to heart health.

A. The blood was infused too quickly and overwhelmed the client's circulatory system. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. Antibodies to donor leukocytes remained in the blood.

Correct Answer is B

Explanation

A. The blood was infused too quickly and overwhelmed the client's circulatory system:

While infusing blood too quickly can lead to circulatory overload and related complications like heart failure or pulmonary edema, it is not the cause of an acute hemolytic transfusion reaction. Acute hemolytic reactions occur due to immune responses against incompatible donor blood.

B. The donor blood was incompatible with that of the client:

This is the correct answer. An acute hemolytic transfusion reaction happens when there is an incompatibility between the donor's blood and the recipient's blood. This can occur due to mismatched ABO blood types or Rh factor, leading to the recipient's immune system attacking and destroying the transfused red blood cells.

C. The client had a sensitivity reaction to a plasma protein in the blood:

Sensitivity reactions to plasma proteins can occur, but they typically result in different types of transfusion reactions, such as allergic reactions or febrile non-hemolytic reactions. These reactions are caused by antibodies to specific plasma proteins and are not the cause of acute hemolytic transfusion reactions.

D. Antibodies to donor leukocytes remained in the blood:

This option refers to febrile non-hemolytic transfusion reactions, which occur due to antibodies against donor leukocytes. However, this type of reaction is distinct from acute hemolytic reactions, which are primarily caused by ABO or Rh incompatibility.

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The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?

Correct Answer is B

Explanation

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