Author Question: A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional ... (Read 51 times)

jrubin · **on:** Jun 25, 2018

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

Question 2

A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume?

(Record your answer using a whole number.) ___ mL

sierrahalpin · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

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.

Answer to Question 2

ANS:
660 mL
A low tidal volume of 6 mL/kg is used to prevent lung injury.
242 pounds = 110 kg.
110 kg 6 mL/kg = 660 mL.