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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

P wave touching the T wave

Midsternal chest pain

Increased urine output

Mild orthostatic hypotension

Answer and Explanation

The Correct Answer is B

A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.

B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.

C. Increased urine output is not an urgent concern in this context.

D. Mild orthostatic hypotension is not as urgent as chest pain.

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Correct Answer is D

Explanation

A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.

B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.

C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.

D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.

A. A client with multiple abdominal drains B. A client with right leg cellulitis C. A client who has viral pneumonia D. A client with chronic heart failure

Correct Answer is D

Explanation

A. Multiple abdominal drains increase infection risk.

B. Cellulitis poses a high risk of infection.

C. Viral pneumonia is contagious and poses a high infection risk.

D. Chronic heart failure does not pose an infection risk, making this the safest roommate choice.

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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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