A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information:

Heart rate: 92/min

Rhythm: Irregular

P wave: Unable to identify

PR interval: Unable to measure

QRS duration: O. 1 0 seconds
Based upon this information, the nurse should interpret the client's rhythm as indicating which of the following?

Atrial fibrillation

Sinus bradycardia

Supraventricular tachycardia

First-degree heart block

Answer and Explanation

The Correct Answer is A

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and irregular ventricular response. The heart rate in atrial fibrillation can be variable, and the absence of identifiable P waves indicates disorganized atrial electrical activity.

B. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute (bpm) and normal P waves preceding each QRS complex. In sinus bradycardia, the PR interval and QRS duration are typically within normal limits.

C. Supraventricular tachycardia: Supraventricular tachycardia (SVT) is characterized by a regular rhythm with a heart rate greater than 100 bpm. SVT typically presents with narrow QRS complexes and may or may not have discernible P waves.

D. First-degree heart block: First-degree heart block is characterized by a prolonged PR interval (>0.20 seconds) but maintains a regular rhythm with normal QRS duration. In first-degree heart block, P waves are typically identifiable, and the rhythm is not irregular.

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Correct Answer is B

Explanation

A. Myopia: Myopia refers to nearsightedness, which is caused by refractive errors in the eye and is not associated with Meniere's disease. Myopia results in difficulty seeing distant objects clearly.

B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease and is caused by an excessive accumulation of endolymph fluid in the inner ear. Vertigo presents as a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance.

C. Photophobia: Photophobia refers to sensitivity to light, which can be associated with various eye conditions but is not a typical manifestation of Meniere's disease. Photophobia may occur in conditions such as migraine headaches or certain eye infections.

D. Presbycusis: Presbycusis refers to age-related hearing loss, which typically occurs gradually over time and is not directly associated with Meniere's disease. Meniere's disease is characterized by sudden episodes of vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in the ear.

A. "l stopped taking aspirin last week." B. "l did not put my contact lenses in this morning." C. "l took my blood pressure meds with a sip of water." D. "l had a cough and runny nose a couple days ago."

Correct Answer is D

Explanation

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Meniere’s disease. The nurse identifies that which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

Correct Answer is B

Explanation

A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

Correct Answer is D

Explanation

A nurse is reinforcing teaching to a group of high school students about how penetrating traumatic brain injuries cause damage to the brain. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

A nurse is providing care for a client following a cardiac arrest due to pulseless electrical activity (PEA). Which of the following alterations are causes of PEA? (Select All that Apply.)

A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?

A nurse is planning care for a client who has hypertrophic cardiomyopathy that has not improved after pharmacologic treatment. Which of the following procedures should the nurse anticipate the health care provider ordering?

A nurse is teaching a client who is newly diagnosed with Alzheimer's disease and their family about newly prescribed medications for Alzheimer's disease. Which statement by the client indicates the teaching was effective?