Nokea
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?
- A. Atrial fi brillation
- B. Ventricular tachycardia.
- C. Premature ventricular contractions (PVCs).
- D. Third-degree heart block.
Correct Answer: C
Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.
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A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
- A. Pinkish red.
- B. Dark yellow-orange.
- C. Clear.
- D. Green.
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
Which of the following is normal for a client during the icteric phase of viral hepatitis?
- A. Tarry stools.
- B. Yellowed sclera.
- C. Shortness of breath.
- D. Light, frothy urine.
Correct Answer: B
Rationale: The icteric phase involves jaundice, causing yellowed sclera (B) due to bilirubin buildup. Tarry stools (A) indicate bleeding, not typical. Shortness of breath (C) and frothy urine (D) are unrelated.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
- A. Encouraging the client to speak slowly.
- B. Allowing extra time for the client to respond.
- C. Asking the client to repeat indistinguishable words.
- D. Asking the client to speak louder when tired.
Correct Answer: D
Rationale: Asking the client to speak louder when tired is contraindicated, as it may exacerbate fatigue and worsen speech. Encouraging slow speech, allowing time, and repeating words support communication.
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
- A. Call the Post Anesthesia Care Unit (PACU).
- B. Call the primary care physician.
- C. Call the respiratory therapist.
- D. Call the Rapid Response Team.
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.
The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.