Nokea
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
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A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by
- A. increasing oxygen flow.
- B. elevating the head of the bed to 90 degrees.
- C. turning and repositioning the patient on his side.
- D. suctioning the patient at least hourly.
Correct Answer: C
Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
Which of the following statements regarding proper use of a cane is correct?
- A. When standing, the cane should reach a height even with the natural waist.
- B. When walking downstairs, the cane should be placed down on the step first, followed by the injured leg, and then the good leg.
- C. The elbow should be straight when holding the cane.
- D. The cane should be held in the hand of the same side that needs support.
Correct Answer: B
Rationale: Downstairs, the cane and injured leg move first, followed by the good leg, ensuring stability. The cane is held opposite the injured side, with the elbow slightly bent, and reaches hip level.
Four clients are to receive medication. Which client should receive medication first?
- A. A client with an apical pulse of 72 receiving Lanoxin (digoxin) PO daily
- B. A client with abdominal surgery receiving Phenergan (promethazine) IM every 4 hours PRN for nausea and vomiting
- C. A client with labored respirations receiving a stat dose of IV Lasix (furosemide)
- D. A client with pneumonia receiving Polycillin (ampicillin) IVPB every 6 hours
Correct Answer: C
Rationale: A stat dose of Lasix for labored respirations indicates an urgent need to address potential pulmonary edema, prioritizing this client.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A. Place the client in a sitting position.
- B. Administer acetaminophen (Tylenol).
- C. Pinch the soft lower part of the nose.
- D. Apply ice packs to the forehead.
Correct Answer: C
Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.