Four hours after a total knee replacement, a 78-year-old client is found to have a heart rate of 110 bpm. The nurse should assess the client for:
A)
cardiac arrhythmia.
B)
pain.
C)
hypothermia.
D)
elevated blood pressure.
B
Explanation:
A)
Tachycardia is often a sympathetic nervous system response to pain, which commonly occurs following this type of surgery. Detection of cardiac arrhythmias requires telemetry monitoring. If pain is not found, then client should be monitored for temperature and blood pressure changes.
Analysis
Assessment
Physiological Integrity: Reduction of risk potential
B)
Tachycardia is often a sympathetic nervous system response to pain, which commonly occurs following this type of surgery. Detection of cardiac arrhythmias requires telemetry monitoring. If pain is not found, then client should be monitored for temperature and blood pressure changes.
Analysis
Assessment
Physiological Integrity: Reduction of risk potential
C)
Tachycardia is often a sympathetic nervous system response to pain, which commonly occurs following this type of surgery. Detection of cardiac arrhythmias requires telemetry monitoring. If pain is not found, then client should be monitored for temperature and blood pressure changes.
Analysis
Assessment
Physiological Integrity: Reduction of risk potential
D)
Tachycardia is often a sympathetic nervous system response to pain, which commonly occurs following this type of surgery. Detection of cardiac arrhythmias requires telemetry monitoring. If pain is not found, then client should be monitored for temperature and blood pressure changes.
Analysis
Assessment
Physiological Integrity: Reduction of risk potential
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