A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.
You might also like to view...
When the nurse sends a text message, the nurse is using what form of communication?
1. Nonverbal communication 2. Verbal communication 3. Telephone communication 4. Body language
A nurse is on the treadmill exercising, when the woman next to her says, "You're a nurse. Explain to me how the scale says I've lost weight, but my waist and tummy just keep getting larger." Which of the following would be the most appropriate response by
a. "I'm concerned. You need to see your health care provider to follow up on this." b. "Muscle weighs more than fat so you're creating muscle while losing fat, but it takes a while for the body to redistribute the weight." c. "Tell me what you've been eating in the last week or so." d. "You're running so you're strengthening your legs and thighs, but to lose around your tummy, you have to exercise your abdominal muscles."
The nurse is preparing a newborn for a circumcision. Which of the following data would be important for the nurse to report to the physician prior to the procedure?
1. The mother took anticoagulants prenatally. 2. The mother is breastfeeding the newborn. 3. The newborn's Apgar scores were 8 and 9. 4. The newborn has had six wet diapers within the last 12 hours.
The perinatal nurse explains to the student nurses that as a result of the Term Breech Trial, a trial of labor is the standard of care for a woman whose fetus is in a breech presentation
A) True B) False