Nokea
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?
- A. Pacemaker spike on the T wave
- B. Pacemaker spike before the P wave
- C. Occasional wide and distorted QRS complex
- D. Prolonged PR interval with normal QRS complex
Correct Answer: B
Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (B), followed by normal conduction. Spikes on T waves (A) are abnormal, wide QRS (C) suggests ventricular issues, and prolonged PR (D) is unrelated to pacing.
You may also like to solve these questions
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.
- A. Educate newly admitted client on the importance of using the call light for assistance
- B. Place the bedside commode as close to the bed as possible
- C. Remind client to change position slowly
- D. Report observations of changes in client’s condition immediately
- E. Report whether client is using correct gait and balance while ambulating with walker
Correct Answer: B,C,D
Rationale: UAP can place commodes (B), remind about slow position changes (C), report condition changes (D), and observe gait (E). Education (A) requires nursing judgment, unsuitable for delegation.
The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased
- A. Use of accessory muscles
- B. Blood pressure
- C. Level of anxiety
- D. Heart rate
Correct Answer: A
Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (B), anxiety (C), or heart rate (D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.
The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
A 2-year old is hospitalized with gastroenteritis and dehydration. Which of the following methods is best for evaluating changes in skin turgor?
- A. Pinching the abdominal tissue while the client is supine
- B. Pinching the tissue of the forearm while the client is sitting
- C. Pressing the skin of the lower extremities while the client is supine
- D. Pinching the skin of the lower extremities while the client is sitting
Correct Answer: A
Rationale: Pinching abdominal tissue while supine is the best method to assess skin turgor in a dehydrated child, as it reflects hydration status accurately.
The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?
- A. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
- B. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
- C. Client with obsessive-compulsive disorder who refuses to attend group therapy because it interrupts handwashing ritual
- D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers
Correct Answer: B
Rationale: Suicidal ideation with a plan (B) poses an immediate safety risk, requiring urgent assessment despite one-to-one observation. Bulimia (A) and schizophrenia (D) behaviors need monitoring but are less acute. OCD refusal (C) is a lower priority, as it does not indicate immediate harm.