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: 0.10 seconds.

Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?

Supraventricular tachycardia.

Atrial fibrillation.

Sinus bradycardia.

First-degree heart block.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.

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Correct Answer is B

Explanation

Choice A rationale
Fever. This statement is incorrect. While fever can occur in clients with ITP due to infections, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice B rationale
Ecchymosis. This statement is correct. Ecchymosis, or bruising, is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies. Clients with ITP are prone to bruising and bleeding even with minor trauma.
Choice C rationale
Fatigue. This statement is incorrect. While fatigue can occur in clients with ITP due to anemia or chronic illness, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice D rationale
Elevated WBC. This statement is incorrect. Elevated white blood cell counts are not typically associated with ITP, which primarily affects platelet counts. An elevated WBC may indicate infection or inflammation but is not specific to ITP10111213.

A. Instruct to slowly exhale with pursed lips. B. Assess pulse and respirations. C. Assess characteristics of her sputum. D. Auscultate lung fields.

Correct Answer is D

Explanation

Choice A rationale
Instructing to slowly exhale with pursed lips is a breathing technique but not the first action to take before the procedure.
Choice B rationale
Assessing pulse and respirations is important but not the first action to take before the procedure.
Choice C rationale
Assessing characteristics of her sputum is important but not the first action to take before the procedure.

Choice D rationale
Auscultating lung fields is the first action to take to assess the client’s current respiratory status and determine the effectiveness of the upcoming procedure.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

Correct Answer is B

Explanation

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Correct Answer is D

Explanation

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Increased heart rate. Discomfort at the puncture site. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

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A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours. Which of the following categories of shock should the nurse recognize is occurring?

A nurse is caring for a school-age child who has leukemia. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

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