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. Notify the blood bank of the discrepancy:

This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.

B. Administer the blood as ordered:

This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.

C. Complete an incident report:

Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.

D. Contact the provider for further orders:

Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.

A. initiate cardiopulmonary resuscitation. B. Administer sublingual nitroglycerin to allow the client to finish the test. C. Stop the test and monitor the client closely. D. Administer analgesia and slow the test.

Correct Answer is C

Explanation

A. Initiate cardiopulmonary resuscitation (CPR): CPR is not indicated in this scenario unless the client experiences a cardiac arrest. Chest pain during an exercise stress test does not automatically warrant CPR.

B. Administer sublingual nitroglycerin to allow the client to finish the test: Nitroglycerin is typically used to relieve angina (chest pain) associated with myocardial ischemia. However, in this case, the exercise stress test should be stopped to evaluate the cause of the chest pain before administering nitroglycerin.

C. Stop the test and monitor the client closely: This is the correct action. Chest pain during an exercise stress test may indicate myocardial ischemia (lack of blood flow to the heart muscle), and stopping the test allows for further assessment and evaluation of the client's condition.

D. Administer analgesia and slow the test: Administering analgesia (pain medication) is not appropriate without first determining the cause of the chest pain. Slowing the test may not address the underlying issue and could potentially worsen the client's condition if they are experiencing cardiac-related chest pain.

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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

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Correct Answer is C

Explanation

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