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The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
- A. Atrial fibrillation.
- B. Ventricular tachycardia.
- C. Premature ventricular contractions.
- D. Sinus tachycardia.
Correct Answer: D
Rationale: Sinus tachycardia is a fast but regular rhythm originating from the sinoatrial node, typically occurring in response to factors like pain, fever, anxiety, or myocardial infarction.
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The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.
- A. I may still need pain medication while this patch is applied.
- B. If the patch comes loose, I may reinforce it with a piece of tape.
- C. I can apply heat to the patch site to increase the pain relief.
- D. I should remove this patch while I am sleeping.
- E. The patch will need to be changed every 72 hours.
Correct Answer: A,B,E
Rationale: A: Breakthrough pain may require additional medication. B: Taping a loose patch is acceptable. E: Fentanyl patches are typically changed every 72 hours. C is incorrect because heat can increase absorption and risk toxicity. D is incorrect as patches are not removed during sleep.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
- A. Apply sunscreen only after going into the water.
- B. Avoid peak exposure hours from 9 a.m. to 1 p.m.
- C. Wear loosely woven clothing for added ventilation.
- D. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
Correct Answer: D
Rationale: Applying sunscreen with SPF 15 or higher before sun exposure is a key measure to prevent UV damage. Sunscreen should be applied before water exposure, peak hours are 10 a.m. to 4 p.m., and tightly woven clothing is better for protection.
To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:
- A. Use blow bottles.
- B. Turn in bed.
- C. Take deep breaths.
- D. Cough.
Correct Answer: C
Rationale: Deep breathing exercises post-hypophysectomy help expand lungs and prevent atelectasis, reducing respiratory complications.
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.